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State of Arizona
Office
of the
Auditor General
PERFORMANCE AUDIT
DIVISION OF BEHAVIORAL
HEALTH SERVICES—
Reporting Requirements
Report to the Arizona Legislature
By Debra K. Davenport
Auditor General
DEPARTMENT
OF
HEALTH SERVICES
December 2001
Report No. 01-33
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee
composed of five senators and five representatives. Her mission is to provide independent and impar-tial
information and specific recommendations to improve the operations of state and local government
entities. To this end, she provides financial audits and accounting services to the state and political
subdivisions and performance audits of state agencies and the programs they administer.
The Joint Legislative Audit Committee
Senator Ken Bennett, Chairman
Representative Roberta L. Voss, Vice-Chairman
Senator Herb Guenther Representative Robert Blendu
Senator Dean Martin Representative Gabrielle Giffords
Senator Peter Rios Representative Barbara Leff
Senator Tom Smith Representative James Sedillo
Senator Randall Gnant (ex-officio) Representative James Weiers (ex-officio)
Audit Staff
Shan Hays—Manager
and Contact Person (602) 553-0333
Angelica Gonzalez—Team Leader
Kirk Jaeger—Team Member
Kristie Waldron—Team Member
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
(602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553 -0333 • FAX (602) 553-0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
December 10, 2001
Members of the Arizona Legislature
The Honorable Jane Dee Hull, Governor
Dr. Catherine R. Eden, Director
Department of Health Services
Transmitted herewith is a report of the Auditor General, a review of the reporting
requirements in Arizona’s behavioral health system. This report is in response to Laws 2001,
Chapter 195, §1 which directed this Office to identify any duplicative or outdated reporting
requirements, look for ways to streamline reports, and consider criteria that measure the
performance of the Division of Behavioral Health Services (Division) in the Department of
Health Services. I am also transmitting with this report a copy of the Report Highlights for
this review to provide a quick summary for your convenience.
As outlined in its response, the Department of Health Services agrees with all of the findings
and recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on December 11, 2001.
Sincerely,
Debra K. Davenport
Auditor General
Enclosure
i
OFFICE OF THE AUDITOR GENERAL
SUMMARY
The Office of the Auditor General has conducted a review of the
reporting requirements in Arizona’s behavioral health system.
Laws 2001, Chapter 195, §1 directed the Office to identify any
duplicative or outdated reporting requirements, look for ways to
streamline reports, and consider criteria that measure the per-formance
of the Division of Behavioral Health Services (Division)
in the Department of Health Services.
The Division, its contracted Regional Behavioral Health Authori-ties
(RBHAs), and their contracted providers prepare reports to
meet legal, contractual, and judicial requirements. In total, audi-tors
identified 63 reports prepared by these organizations. The
reports enable the Division and its funding organizations, in-cluding
the Arizona Health Care Cost Containment System
(AHCCCS), to monitor essential aspects of system performance
such as service quality, client protection, continued availability of
services, and financial accountability.
The Division Can Streamline
Some Reports and
Eliminate Others
(See pages 5 through 13)
Although most of the 63 reports are necessary to oversee the be-havioral
health system and qualify to receive federal monies, the
Division recently combined 2 reports and can eliminate 6 others
without compromising oversight of the behavioral health system
or losing federal funding. In addition, it can make other im-provements
to simplify reporting. Combining two costly and
time-consuming case file reviews, and their associated reports,
should satisfy federal requirements while reducing the burden
on RBHAs and service providers. One of these reviews, called
the Independent Quality Evaluation, entailed hiring an inde-pendent
reviewer to examine a sample of cases for a specific
population, such as substance-abusing pregnant women, or
The Division can elimi-nate
six reports.
Summary
ii
OFFICE OF THE AUDITOR GENERAL
people with schizophrenia. The other review, called the Medi-caid
Case File Review, involved review by RBHA staff of a sam-ple
of Medicaid client files for compliance with federal regula-tions.
The Division and AHCCCS combined these two reviews
through a contract amendment effective October 3, 2001.
Six additional reports can potentially be eliminated, including
three outdated reports that were originally established by the
Legislature. The reports that may be eliminated are:
¾ Three financial and claims reports that are duplicative or un-necessary,
including two reports on the use of tobacco tax
monies.
¾ A report requested by a former legislator to monitor shifts of
appropriated monies. Such shifts can no longer occur due to
a law passed in 2000.
¾ A report established to monitor spending of a special appro-priation.
This requirement in an appropriation footnote has
ended.
¾ A report based on an involuntary commitment statute for
chronic alcoholics. No such commitments have occurred in
recent years, so no report has been prepared. The Legislature
should consider reviewing and revising the statute and then,
if appropriate, eliminating the associated report.
However, three other reports related to settlements on two class-action
lawsuits appear necessary to demonstrate progress to-ward
meeting the lawsuit settlement agreements. These reports
cannot be eliminated or streamlined until the court and plaintiffs
are satisfied with the State’s performance.
Finally, the Division could simplify reporting if it can improve
the data entry process for its two databases. Specifically, it
should continue its efforts to enable the RBHAs to send data re-cords
only once, instead of sending them separately to both da-tabases.
Summary
iii
OFFICE OF THE AUDITOR GENERAL
Division Can Continue To
Improve Performance
Measurement in Four Key Areas
(See pages 15 through 22)
The Division measures performance in all four areas auditors
were directed to consider, although performance measurement
can be improved in each area. First, the Division measures clini-cal
quality in several ways, including case file reviews and a va-riety
of other oversight activities. It should continue its progress
in developing service-planning guidelines that identify best prac-tices
for specific client diagnoses. Second, the Division measures
service availability, using provider network reports, waiting list
information, and reports on the length of time clients wait to re-ceive
services. However, it has only recently developed uniform
definitions for some service availability performance measures. It
should use these new measures consistently in the future. Third,
the Division measures quality of service as rated by the patient or
the patient’s family, primarily through a Statewide Consumer
Perception Survey administered by mail. However, this meas-urement
is hampered by low survey responses. The Division
should use alternative survey administration methods in order
to obtain more meaningful results.
Finally, the Division currently measures the fourth area, quality
of RBHA services as rated by providers, for only one of the five
RBHAs. This measurement is part of the Incentive Pilot Program
established in 1994. Although provider dissatisfaction with
RBHA services does not appear to be widespread, the Division
should consider surveying providers statewide in order to iden-tify
and address any problems. The relationship between RBHAs
and providers is important because the Division relies on both to
deliver services to clients, and unresolved dissatisfaction might
affect the quality of behavioral health services clients receive.
The Division measures
clinical quality in several
ways.
iv
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
v
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS
Page
Introduction and Background....................... 1
Finding I: The Division Can
Streamline Some Reports
and Eliminate Others................................. 5
Two Costly and Time-Consuming
Case File Reviews and Reports
Were Recently Combined.......................................... 5
Six Reports Can
Be Eliminated .............................................................. 7
Reports Related To Judgments
on Class-Action Lawsuits
Are Still Needed.......................................................... 10
Procedural Improvement
Could Simplify Reporting.......................................... 11
Recommendations...................................................... 13
Finding II: Division Can Continue
To Improve Performance
Measurement in Four Key Areas............. 15
Clinical Quality Measured
in Several Ways but Measurement
Can Be Improved........................................................ 15
Division Is Making Progress in
Measuring Service Availability ................................. 17
Table of Contents
vi
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS (Concl’d)
Page
Finding II: (Concl’d)
Quality-of-Service Ratings
Are Hampered by
Low Survey Responses .............................................. 18
RBHA Services Rated by
Providers for Only One
of Five RBHAs............................................................. 20
Recommendations...................................................... 22
Appendix.......................................................... a-i
Agency Response
1
OFFICE OF THE AUDITOR GENERAL
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a review of the
reporting requirements in Arizona’s behavioral health system.
Laws 2001, Chapter 195, §1 directed the Office to identify any
duplicative or outdated reporting requirements, look for ways to
streamline reporting, and consider criteria that measure the Divi-sion’s
performance.
Arizona’s behavioral health system is administered by the De-partment
of Health Services’ Division of Behavioral Health Ser-vices
(Division), which provides publicly funded mental health
services and substance abuse treatment and prevention services.
According to the Division, in fiscal year 2001, the Division re-ceived
approximately $389 million, including about $199 million
in Title XIX (Medicaid) monies from the Arizona Health Care
Cost Containment System (AHCCCS) and $39.2 million in non-
Title XIX federal monies. All but approximately $15.5 million
was allocated among five contracted Regional Behavioral Health
Authorities (RBHAs), which operate like health maintenance or-ganizations
to coordinate services in their geographic regions.
The RBHAs contract with a network of more than 350 service
providers to offer a broad range of behavioral health services to
over 100,000 consumers throughout the State.
Sources of Reporting
Requirements
Each organization in the behavioral health system, including the
Division, the RBHAs, and the service providers, prepares reports
to meet contractual, legislative, and judicial requirements. The
Appendix (see pages a-i through a-xiii) lists 63 required reports
and the primary sources establishing the requirements. The three
main sources of reports are:
¾ State and Federal Requirements—Forty of the 63 reports
are prepared in response to state and federal laws and regu-lations.
Arizona laws and regulations establish require-
Sixty-three reports origi-nate
from contractual re-quirements,
legislative re-quests
or mandates, and
judicial mandates.
Introduction and Background
2
OFFICE OF THE AUDITOR GENERAL
ments for 13 of these 40 reports. For example, an Arizona
statute requires the Division to submit monthly reports on
expenditures, persons served, and units of service. Federal
laws and regulations, including those governing the use of
Medicaid, establish the other 27 of the 40 reporting require-ments.
¾ Contractual/Grant Requirements—Twenty additional re-ports
are required by contracts or grants. The primary
sources for 10 reports are contracts between AHCCCS, the
Division, the RBHAs, and the providers. For example, the
Division’s contracts with the RBHAs and the RBHAs’ con-tracts
with their providers establish reports to monitor spend-ing,
services, and compliance with state laws, and to gather
information needed for the Division’s reports to AHCCCS.
The primary sources for the remaining ten reports are grants
from the federal government, which include reporting re-quirements
as a condition of receiving grant monies. Cur-rently,
the Division, RBHAs, and providers have grants from
several federal programs. The majority of these grants are
funded by the Substance Abuse and Mental Health Services
Administration (SAMHSA), a federal agency within the De-partment
of Health and Human Services.
¾ Judicial Requirements—Finally, judicial requirements dic-tate
the preparation of three reports. One report and a case
file review are prepared as a result of the Arnold v. Sarn law-suit.
1 The Division prepares these items to show progress
toward meeting the criteria for exiting the lawsuit. Beginning
in November 2001, a more recent lawsuit settlement, J.K. v.
Eden, will also require a report.2
1 In 1981, the Superior Court of Arizona found that the Department of
Health Services did not provide the level of services promised in state law
to seriously mentally ill persons in Maricopa County. An agreement nego-tiated
with the plaintiffs in 1995 establishes criteria for exiting the lawsuit,
and until those criteria are met, a court-appointed monitor oversees com-pliance
with the court-ordered agreement.
2 The Division and AHCCCS entered into a settlement in 2001 to resolve a
10-year-old lawsuit filed on behalf of AHCCCS-eligible children who need
mental health services. The agreement is based on a set of principles that
stress family involvement and collaboration among agencies.
Introduction and Background
3
OFFICE OF THE AUDITOR GENERAL
Purposes of
Reporting
Collectively, the behavioral health system reports serve as moni-toring
tools for the Division and its funding organizations, includ-ing
AHCCCS and the federal government. Oversight of the be-havioral
health system is critical to ensure that clients receive
needed, quality services. Reporting on availability and quality of
services is particularly important under Arizona’s system because
RBHAs receive payment in advance, based on a capitated rate per
Medicaid-eligible person, instead of receiving payment for ser-vices
once they have been delivered. This approach can help con-trol
costs, but may also give RBHAs an incentive to keep their
own costs down by limiting care. As indicated in a 1999 perform-ance
audit of the Division (Auditor General Report No. 99-12), the
Division has made substantial efforts to improve oversight com-pared
to previous audits, including improving the way it moni-tors
RBHA performance through required reports. Behavioral
health system reports enable oversight of several essential aspects
of contractor performance:
¾ Service to clients, including appropriateness based on the
client’s diagnosis, timeliness of services, use of appropriate
assessments, treatment planning, treatment delivery by
qualified individuals, and client and family satisfaction with
services;
¾ Client outcomes, measured using clinical scores that show
changes in client condition; for example, decreased substance
abuse, as well as client and family satisfaction with outcomes,
and mortality rates;
¾ Client protection, including monitoring client rights, treat-ing
clients in the least restrictive environment possible, and
addressing grievances, appeals, and incidents of fraud or
abuse appropriately;
¾ Continued availability of services, measured by adequacy
of the existing provider network in offering services in geo-graphic
areas, as well as by contractors’ financial viability; and
Oversight of the behav-ioral
health system is
critical to ensure that
clients receive needed,
quality services.
Introduction and Background
4
OFFICE OF THE AUDITOR GENERAL
¾ Financial accountability, including compliance with restric-tions
on the use of state and federal monies.
Scope and Methodology
This review addresses the following purposes identified in Laws
2001, Chapter 195, §1 regarding behavioral health system re-ports:
¾ To identify duplicative and outdated reporting requirements
and recommend ways that the reporting requirements can be
streamlined into a more meaningful format.
¾ To consider criteria that measure the Division’s performance,
including clinical quality, availability of services, quality of
service as rated by the patient or patient’s family, and quality
of RBHA services as rated by service providers.
To address these issues, auditors reviewed reporting require-ments
established in contracts, legislation, and court decisions;
interviewed Division, RBHA, and provider staff to identify other
reports they prepare; examined and compared reports to their
reporting requirements; and interviewed report recipients about
the way they use the reports and the effect of eliminating or
streamlining the reports.
This report contains recommendations in two areas:
¾ The Division can streamline some reports and eliminate oth-ers.
¾ The Division can continue to improve performance meas-urement
in four key areas.
The report also includes an Appendix (see pages a-i through a-xiii)
that lists 63 reports required by the behavioral health system.
The Auditor General and staff express appreciation to the Direc-tor
of the Department of Health Services, the Deputy Director of
the Division of Behavioral Health Services, the RBHAs,
AHCCCS, and their staff for their cooperation and assistance
throughout the review.
5
OFFICE OF THE AUDITOR GENERAL
FINDING I THE DIVISION CAN
STREAMLINE SOME REPORTS
AND ELIMINATE OTHERS
The Division has the opportunity to combine some reports and
eliminate others without compromising oversight of the behav-ioral
health system. Two of the 63 reports currently produced
were consolidated during the audit because they are essentially
similar, and 6 others can be eliminated because they are no
longer necessary. However, 3 reports prepared as a result of the
settlement of two class-action lawsuits cannot be combined or
eliminated until the court and plaintiffs are satisfied with the
State’s performance. Still, the Division can simplify and stream-line
processes for the remaining reports by eliminating the need
to enter data into two separate computer databases.
Two Costly and Time-Consuming
Case File Reviews and Reports
Were Recently Combined
Until October 3, 2001, the Division conducted two extensive but
similar case file reviews, with each review resulting in a separate
report covering such issues as quality and appropriateness of
care. Both examined large, statistically valid samples of client
files across all RBHAs, and both were conducted to satisfy fed-eral
mandates. Because the two reviews and reports had similar
purposes, included some of the same information, and relied on
some of the same case files, the reviews have been combined.
This should significantly reduce the reporting burden on RBHAs
and their providers. The two file reviews were as follows:
¾ Independent Quality Evaluation—This annual review was
conducted to satisfy a federal requirement. It evaluated qual-ity
of care for a selected client group or diagnosis by assess-ing
treatment approaches, comparing treatment provided
Combining two extensive
but similar case file reviews
will significantly reduce
the reporting burden.
Finding I
6
OFFICE OF THE AUDITOR GENERAL
against service-planning guidelines, and reviewing client
outcomes. A different client group or diagnosis was chosen
each year. For example, the review and report addressed
children in 1999, substance-abusing pregnant women in 2000,
and people with schizophrenia in 2001. Federal regulations
mandate that an independent reviewer conduct this review.
The Division spent approximately $350,000 per year on it, us-ing
administrative dollars provided by AHCCCS.
The review placed substantial demands on the RBHAs and
their providers. The provider file samples reviewed have
ranged from 122 to 1,689 total cases, depending on the topic.1
RBHAs and providers had to gather case files from all their
locations, prepare or copy them for review, and assist the
independent reviewers by answering questions and helping
set up meetings with key RBHA and provider staff. Given
the review’s size, this work was extensive. For example, in
2001, one provider reported spending 175 staff hours making
copies of client files for the independent reviewer.
¾ Medicaid Case File Review—This review, also conducted
annually to satisfy a federal mandate, assessed compliance
with federal requirements for Title XIX/XXI clients, includ-ing
timeliness of treatment, whether services are rendered by
providers with appropriate expertise, quality of care, and cli-ent
outcomes. A federal regulation allows qualified staff or
an independent evaluator to conduct this review. Using Divi-sion
records, auditors estimated that the 1999 review, con-ducted
by RBHA staff, cost approximately $75,000.2
1 For the 2001 evaluation, AHCCCS and the Division initially agreed on a
sample size of 2,371 client files. In order to reduce the burden on provid-ers,
the sample size was reduced to 1,689 before the evaluation was con-ducted.
2 Auditors calculated this figure using 1999 Arizona Community Behavioral
Health Wages information for clinically qualified staff and BHS staff esti-mates
of time spent reviewing case files. Source: Information provided by
the Division, using 4th Quarter 1999 State Occupational Employment-Arizona
and Wage Estimates and 4th Quarter 1999 National Occupational Employment
and Wage Estimates.
Finding I
7
OFFICE OF THE AUDITOR GENERAL
Like the Independent Quality Evaluation, this review placed
demands on both RBHAs and providers. The 1999 review
examined 1,189 case files. In addition to gathering and pre-paring
the files for review, the RBHAs supplied qualified
staff who conducted the reviews using a 94-question Quality
of Care Case File Instrument.
The Division and AHCCCS began discussing the potential for
combining the two reviews during the audit, and combined
them in an October 3, 2001, contract amendment. To meet federal
requirements, an independent evaluator will need to conduct the
combined review. An AHCCCS official believes a statistically
valid, independent review of a target population, including a re-view
of the factors currently assessed in the Medicaid case file
review, will satisfy both requirements. Because approximately 50
percent of the Division’s clients are not Title XIX/XXI eligible,
the Division will also need to ensure that these individuals are
included in the combined review.
Six Reports
Can Be Eliminated
Six of the behavioral health system’s 63 reports are no longer
necessary and can therefore be eliminated without affecting
oversight of behavioral health programs. Three of these six re-ports
are either not used at all or contain information that is
available in other reports. Two of the six are prepared in re-sponse
to earlier legislative mandates that are no longer applica-ble.
A sixth report pertains to a statutory provision that is out-dated
and has not been used in some time. In addition, the Divi-sion
should eliminate the annual reporting requirement for the
cost allocation plan and require reports only when the cost allo-cation
method changes.
Three financial and claim reports are duplicative or unneces-sary—
Three reports appear unnecessary because they duplicate
material in other reports or are not used at all. Although elimi-nating
any one of these reports would not result in substantial
time savings for any one provider or RBHA, the combined effect
could be significant. Each report requires preparation at more
than one level in the behavioral health system. Further, at the
The 1999 Medicaid Case
File Review examined
1,189 case files.
Three reports are not used
at all or contain informa-tion
that is available in
other reports.
Finding I
8
OFFICE OF THE AUDITOR GENERAL
RBHA and Division levels, the reports received from providers
and RBHAs are reviewed, combined, and submitted elsewhere.
The three reports are as follows:
¾ Provider Affiliation Tape (also called Provider Network
File)—The RBHAs and the Division use this report to submit
a list of authorized providers and identification numbers for
comparison with AHCCCS’ records. The Division and
AHCCCS recently agreed to replace it with a more efficient
online process for comparing the information. However, as of
October 3, 2001, the contract between AHCCCS and the Divi-sion
still requires this report.1
¾ Tobacco Tax Revenues and Expenditures Report—This
report, which the Division submits to the Department of
Health Services’ budget analyst, is not necessary. The report
explains how each RBHA uses monies from the tobacco tax;
however, the budget analyst uses a different report for this
purpose—the legislatively mandated Tobacco Tax Evalua-tions
Report.
¾ Tobacco Tax Cash Activity Report—Similar to the Tobacco
Tax Statement of Revenue and Expenses, RBHAs prepare
this report for the Department budget analyst, but the analyst
does not use it.
Three legislatively mandated reports no longer needed—In three
cases, reports prepared in response to legislative mandates can
be eliminated. Two of these reports are no longer needed be-cause
the mandate no longer applies. The third, which has not
been prepared in nearly 10 years, relates to a seldom-used pro-cedure
for involuntarily committing a chronic alcoholic for
treatment. The Legislature should consider reviewing the statute
that makes this report necessary.
1 The AHCCCS contract lists this item as two separate reports, a tape and a
file. However, according to the Division, the tape was the physical me-dium
for transmitting the file to AHCCCS. The Division now uses disks
instead of magnetic tapes for transferring computerized records, but the
contract was never modified to delete the reference to the tape.
Two reports are no
longer needed because
the mandate no longer
applies.
Finding I
9
OFFICE OF THE AUDITOR GENERAL
¾ Non-Title XIX/XXI Children’s Behavioral Health Services
Summary (also called Grace Report)—This report, origi-nally
requested by a former legislator to monitor whether
monies appropriated for non-Title XIX children were actually
used for such children, is no longer necessary. Laws 2000,
Chapter 2, §1 prohibits the Division from moving monies
from one budget line item to another, such as from non-Title
XIX children to other uses.
¾ Quarterly Medications Report—This report, prepared in
response to a 2-year legislative requirement that ended in
1999-2000, is no longer necessary. In 1998 and 1999, the Legis-lature
appropriated a total of over $16 million for psychotro-pic
medications, and required the Division to report on how
the monies were being used. This requirement in an appro-priation
footnote has since expired. The Division can con-tinue
to monitor spending on medications through its annual
medications report, without requiring RBHAs to submit this
quarterly report. Information on expenditures for psychotro-pic
medications can readily be gathered from the RBHA
computer systems as needed.
¾ Involuntary Commitment Report—Pursuant to A.R.S §36-
2026.01, the Director of the Local Alcoholism Reception Cen-ter
(LARC), located in Maricopa County, may petition the
court for involuntary commitment of a person deemed a
chronic alcoholic, and must submit a report to the Division
about such commitments. However, the current LARC pro-gram
manager has never petitioned the court for involuntary
treatment, and the Division has not received a report since
1992. Further, since the time this statute was enacted, deliv-ery
of behavioral health services, including alcoholism ser-vices,
changed. The County no longer has primary responsi-bility
for such services, and LARC is now operated by a pri-vate,
nonprofit organization. Additionally, involuntary
commitment is not consistent with best practices in substance
abuse treatment, and there are other ways of treating clients.
The Legislature should consider reviewing and revising the
involuntary commitment statute and eliminating the associ-ated
report, if appropriate.
The Legislature should
consider reviewing the
involuntary commit-ment
statute and the
associated report.
Finding I
10
OFFICE OF THE AUDITOR GENERAL
One financial report not needed annually—The Annual Cost Al-location
Plan, which the Division receives from each RBHA, de-fines
direct and administrative costs and describes the RBHA’s
allocation methodology. The AHCCCS contract with the Divi-sion
sets a limit on recovery of administrative costs at 8 percent
of the value of direct services provided. Further, such costs must
be allowable under the federal Office of Management and
Budget (OMB) Circular A-122. Currently, the Division requires
each RBHA to submit a plan every year. However, the Division
should work with AHCCCS to eliminate the annual requirement
for a complete report, and instead require reports only when the
plans change. If there have been no changes to their plans, the
RBHAs should be required to annually submit a statement that
the existing plan is not outdated.
In addition, the Division should improve its oversight of the
RBHAs by reviewing the plans. Currently, the Division does not
review the plans it receives. However, it should compare the
listed items against approved administrative costs identified by
the OMB Circular, and require the RBHAs to correct their plans
when needed.
Reports Related To
Judgments on Class-Action
Lawsuits Are Still Needed
Three of the 64 reports are related to settlements on two class-action
lawsuits. These reports appear necessary to demonstrate
progress toward meeting the lawsuit and settlement agreements
and cannot be eliminated or streamlined until the court and
plaintiffs are satisfied with the State’s performance. However,
the Division and the Maricopa County RBHA should work with
the court monitor to streamline the process for the lawsuit per-taining
to seriously mentally ill adults. The two suits and related
reports are as follows:
¾ Arnold v. Sarn—The 1995 agreement negotiated by the De-partment
of Health Services and the plaintiffs in the Arnold v.
Sarn lawsuit, which focused on the State’s obligation to seri-ously
mentally ill adults in Maricopa County, includes an
Reports on two class-action
lawsuits appear
necessary to demonstrate
progress until the court
and plaintiffs are satisfied
with the State’s perform-ance.
Finding I
11
OFFICE OF THE AUDITOR GENERAL
annual case review and a regular status report.1 The case re-view
is the primary tool used to demonstrate progress in
meeting the agreement obligations. Specially trained RBHA
staff conduct these reviews, answering 329 questions for each
case based on a review of the file and interviews with the cli-ent,
case manager, and other persons. Division staff certified
by the court monitor review the RBHA staff findings in a
process called case judging. Each of these reviews takes ap-proximately
3 full days to conduct, including the file review,
the interviews, writing the findings, and case judging.
In 1999, the Auditor General suggested the Division consider
having the court monitor conduct the case file reviews as part
of her independent review, since she retained the right to ne-gate
the Division’s findings and had done so in the past (Re-port
No. 99-12). The Division and the court monitor worked
together to develop the current procedure and training, and
hope this will result in agreement on the findings. The Divi-sion
and the court monitor should continue working together
to streamline the process. For example, they could eliminate
questions once the monitor is satisfied that the underlying
criteria have been addressed.
¾ J.K. v. Eden—Under the terms of the settlement in this case,
which addressed AHCCCS-eligible children who need men-tal
health services, the Division is required to prepare an an-nual
action plan describing strategies and activities relating to
agreed-upon obligations, such as statewide training and ex-panding
services for this population.2 In addition, in-depth
case reviews and interviews with family and relevant indi-viduals
in the child’s life are required.
Procedural Improvement
Could Simplify Reporting
In addition to streamlining or eliminating certain reports, the Di-vision
may be able to simplify reporting by improving the data
1 160 Ariz. 593; 775 P.2d 521; 1989, Maricopa County C-432355.
2 J.K. v. Eden, Arizona Federal District Court Case, No. CIV91-261.
Finding I
12
OFFICE OF THE AUDITOR GENERAL
entry process for the Division’s databases. The Division currently
requires RBHAs to enter information separately into two data-bases:
the Client Information System (CIS), which contains bill-ing
information; and the Client Enrollment, Disenrollment, and
Assessment Reporting (CEDAR) system, which contains client
information. Currently, RBHAs transmit partial client data re-cords
from their own computer systems to CIS. CIS assesses the
accuracy and completeness of the record as submitted, and sends
it back to the RBHA. The RBHA then adds demographic and
clinical data and submits the data record to CEDAR. Therefore,
the RBHAs must send each record twice. The Division has begun
exploring ways to enable the RBHAs to send data only once. Di-vision
officials hope to include an improved data entry process
with other changes that will be required by October 2002 to im-plement
the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), which mandates federal standards for comput-erized
systems.
Finding I
13
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. The Division should eliminate the following reports:
a) Provider Affiliation Tape (also called Provider Network File)
b) Tobacco Tax Revenues and Expenditures Report
c) Tobacco Tax Cash Activity Report
d) Non-Title XIX/XXI Children’s Behavioral Health Services
Summary (also called Grace Report)
e) Quarterly Medications Report
2. The Division should work with AHCCCS to eliminate the
annual requirement for the Cost Allocation Plan, and
a) Require reports only as needed when the plans change; and
b) Review the plans and compare them against approved admin-istrative
costs identified by Office of Management and Budget
Circular A-122 and require the RBHAs to correct their plans
when needed.
3. The Legislature should consider reviewing and revising the
involuntary commitment statute for chronic alcoholics in
A.R.S. §36-2026.01 and eliminating the associated report, if
appropriate.
4. The Division should continue working with the court moni-tor
to streamline the Arnold v. Sarn case file review.
5. The Division should continue its efforts to improve the data
entry process for the Client Information System (CIS) and
Client Enrollment, Disenrollment, and Assessment Reporting
(CEDAR) system databases.
14
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
15
OFFICE OF THE AUDITOR GENERAL
FINDING II DIVISION CAN CONTINUE TO
IMPROVE PERFORMANCE
MEASUREMENT IN
FOUR KEY AREAS
The Division measures performance in all four areas auditors
were directed to consider. Most measurement occurs for clinical
quality. The least amount of measurement is done of provider
satisfaction with RBHA services. However, measurement can be
improved in each area.
Laws 2001, Chapter 195, §1 instructed auditors to consider
whether the behavioral health system reports contain criteria that
measure the performance of the Division in the following areas:
¾ Clinical quality,
¾ Availability of services,
¾ Quality of service as rated by the patient or the patient’s fam-ily,
and
¾ Quality of regional behavioral health authority services as
rated by their service providers.
Clinical Quality Measured
in Several Ways but
Measurement Can Be Improved
The Division assesses clinical quality in several ways. However,
the Division should continue its efforts to develop a comprehen-sive
set of service-planning guidelines describing quality-of-care
standards.
Finding II
16
OFFICE OF THE AUDITOR GENERAL
Division has multiple mechanisms for
measuring clinical quality—The Divi-sion
measures clinical quality through
case file reviews. It recently combined
two separate reviews that examine as-pects
of clinical quality, such as whether
services are appropriate and delivered
by qualified providers. One of these re-views,
the Independent Quality Evalua-tion,
examines clinical quality measures using an evaluation tool
composed of quality standards particular to a certain population.
In addition, the Division measures clinical quality in the follow-ing
ways:
¾ Medical care evaluation studies, performed by certain pro-viders,
help to ensure that services are consistent with patient
needs and established health care standards.
¾ Through reports from RBHAs, Division staff examine the use
of client seclusion and physical restraints, and monitor
whether caregivers use the least restrictive method of treat-ment.
¾ Division staff assess the success of clinical treatment methods
by examining how long clients must stay in treatment, and
how often clients must be readmitted for additional treat-ment.
¾ The State’s participation in the Mental Health Statistics Im-provement
Program (MHSIP)1 provides benchmarks for ac-cess
to services, quality of services, appropriateness of ser-vices,
outcomes, and general satisfaction.
The Division uses this information to identify needed improve-ments
and develop plans to address any problems identified. For
example, the medical care evaluation and seclusion and restraint
1 The Mental Health Statistics Improvement Project (MHSIP) is a national
effort to develop benchmarks for mental health services. Arizona is 1 of 16
states participating in the development of these benchmarks under a grant
from the federal Substance Abuse and Mental Health Services Administra-tion.
The Division measures
clinical quality through
case file reviews.
Clinical Quality
Quality of services in
a treatment setting as
determined by ac-cepted
standards
and best practices.
Finding II
17
OFFICE OF THE AUDITOR GENERAL
measures are included in an annual Operational and Financial
Review the Division conducts at each RBHA. A Corrective Ac-tion
Plan is developed to address problem areas identified in this
review.
Division can continue to improve clinical quality assessment—
While the Division has a number of clinical quality measures,
some of them are not tied to a comprehensive set of service-planning
guidelines and best practices. A 1996 Auditor General
report (No. 96-19) recommended that the Division develop stan-dards
of care through service-planning guidelines across the
spectrum of needs it strives to meet. The Division has made pro-gress
in doing so. So far, it has guidelines for 15 client groups or
diagnoses, including substance-abusing pregnant women and
people with schizophrenia. It uses these guidelines to inform
providers and RBHAs of best practices, and to assess client
treatment plans in its case file reviews. However, there are many
other conditions patients are being treated for, such as bipolar
disorder, that currently lack guidelines. The Division needs to
continue its efforts to develop guidelines and standards for other
client diagnoses.
Division Is Making
Progress in Measuring
Service Availability
The Division addresses service availability in two primary ways.
First, it monitors how long it takes clients to receive services by
comparing referral dates to dates of first service, and works with
the RBHAs to develop corrective action plans for addressing
problems. Second, it assesses availability of services by geo-graphic
area, and monitors provider waiting lists for certain cli-ents
and certain types of services. It requires RBHAs to provide
this information in annual provider network reports. In these re-ports,
the RBHAs must identify what services are needed but
unavailable and propose plans to correct service gaps. The Divi-sion
is currently establishing a baseline of provider network ca-pacity,
and plans to take “snapshots” of network changes in an
automated quarterly report. As recommended in the 1999 per-formance
audit of the Division (Report No. 99-12), the Division is
using mapping software to help it assess the sufficiency of the
Network reports show
availability of services by
geographic area.
Finding II
18
OFFICE OF THE AUDITOR GENERAL
statewide provider network. Due to the passage of Proposition
204 in November 2000, which expanded eligibility for services,
analyzing the provider network is an especially important func-tion
at this time to ensure services are available for existing and
new clients. The Division should continue improving the as-sessment
of provider network availability.
Although the Division has made progress in measuring avail-ability,
the measures it uses have not been fully consistent. For
example, the Division only recently defined the term “enrolled,”
which caused some inconsistencies in calculating various per-formance
measures that rely on enrollment. One such measure is
penetration rate, which measures the number of clients enrolled
and served compared to the number of potential clients in the
population. This measure is an aspect of service availability,
since low penetration rates can indicate needed services are not
available. The Division recently developed a uniform definition
for this measure and other terms used to calculate it. The Divi-sion
should use the new definitions consistently and ensure that
it develops complete, uniform definitions when it adds or modi-fies
performance measures in the future.
Quality-of-Service Ratings
Are Hampered by Low
Survey Responses
The Division monitors quality of service as rated by the patient
or the patient’s family primarily through a survey sent to pa-tients
and their families. This is a useful instrument, particularly
because the results can be benchmarked with results from other
states, but low response rates from those surveyed diminish the
meaningfulness of Arizona’s results. The Division can take steps
to increase the response rate.
Consumer Perception Survey offers opportunity to benchmark
Arizona’s performance with other states—The primary meas-urement
tool addressing quality of service as rated by the patient
or the patient’s family is the Statewide Consumer Perception
Survey. The survey assesses client and family satisfaction with
services provided. Every 2 years, the Division and the RBHAs
survey clients. The survey instrument, available in both English
Survey assesses client
and family satisfaction in
four areas.
Finding II
19
OFFICE OF THE AUDITOR GENERAL
and Spanish, measures four areas of satisfaction: access to ser-vices,
quality and appropriateness of services, outcomes, and
general satisfaction. For example, in 1999, clients were asked to
indicate their levels of agreement or disagreement with 25 state-ments,
including:
Ø I like the services that I received here
Ø I was able to get all the services I thought I needed
Ø Staff returned my calls within 24 hours
Ø Staff told me what side effects to watch for
Ø As a result of services, I deal more effectively with daily
problems
Ø As a result of services, I do better in school and/or work
The survey includes questions drawn from the national Mental
Health Statistics Improvement Project (MHSIP), which will allow
the Division to benchmark itself against other states. The Divi-sion
sends survey results to MHSIP, produces a biennial report,
and submits survey results to the Arizona Master List of State
Government Programs to show consumer satisfaction rates.
Low response rate affects reliability of results—While the sur-vey
can provide useful information, the Division needs to im-prove
response rates in order to make the results more meaning-ful.
In 1999, the response rate was only 19 percent, making it im-possible
to generalize results statewide. The 2001 survey yielded
similar low response rates. Both surveys were conducted primar-ily
by mail, a method that often gives poor response rates. To
improve the response rate, the Division needs to consider alter-native
survey administration methods. The MHSIP project work
group is currently evaluating various methods, including face-to-
face interviews conducted by consumers. Other states have
reported response rates as high as 84 percent when using face-to-face
survey methods.
Consumer satisfaction also measured in other ways—In addi-tion
to the Consumer Perception Survey, client satisfaction is also
Division needs to im-prove
response rates by
using alternative sur-vey
administration
methods.
Finding II
20
OFFICE OF THE AUDITOR GENERAL
a factor in two case file reviews, which include interviews with
clients and family members. For example, beginning in Novem-ber
2001, as part of an annual action plan to satisfy J.K. v. Eden
settlement agreement stipulations, the Division will conduct pa-tient
and family interviews as well as case file reviews. This in-formation
will provide the Division additional perceptions of
families’ and children’s quality of care. Finally, one RBHA con-ducts
a consumer survey as part of its pilot incentive program.
RBHA Services Rated by
Providers for Only One
of Five RBHAs
In contrast to its efforts with regard to the three other types of
performance measures auditors were asked to address, the Divi-sion
does relatively little to gather information about the quality
of RBHA services as rated by the providers that contract with
each RBHA. The Division formally measures providers’ percep-tions
of quality at only one RBHA. The Division should consider
measuring such perceptions system-wide.
Provider satisfaction measurement of one RBHA is tied to in-centive
program—The measurement of providers’ satisfaction
with one RBHA is done as part of a pilot incentive program es-tablished
by Laws 1994, Chapter 1, §24.1 The pilot program pro-vides
financial incentives to the RBHA based on providers’ satis-faction
with the services the RBHA provides. For example, in
January 2001, the RBHA received $751 based on the results of a
provider satisfaction survey. Provider staff responded to ten
questions, such as, “Does the RBHA process claims and pay bills
on time?” and “Do you receive the technical assistance you need
from the RBHA?” The results show that provider satisfaction
1 The incentive program includes two other components besides provider
satisfaction. Specifically, both providers and the RBHA can earn incentive
payments based on the results of client and stakeholder surveys. All three
surveys consist of six to ten questions and are administered three times a
year. In fiscal year 2002, a total of $100,000 is available for these incentives.
The January 2001 surveys resulted in incentive payments totaling $2,704
out of a possible $3,004 paid to the RBHA, and $22,441 out of a possible
$29,726 paid to providers. Eleven providers earned incentives in that pe-riod.
The Department of Health Services suggested eliminating this pilot
program in September 2001 as part of its budget reduction proposal.
Finding II
21
OFFICE OF THE AUDITOR GENERAL
improved slightly over the first 5 years of the pilot program. Spe-cifically,
the percentage of providers responding “always” to
these questions increased from approximately 16 percent in 1997
to about 26.5 percent in January 2001.
Division does not survey other RBHAs’ providers—Instead of
surveying other RBHAs’ providers, the Division uses other
means for monitoring provider satisfaction. For example, in ad-dition
to the pilot program, the Division has a grievance mecha-nism
that allows dissatisfied providers to complain. In calendar
year 2000, providers filed 248 grievances, 246 of which were re-lated
to nonpayment. The Division also holds provider forums
and monthly meetings with providers. Results of the pilot pro-gram
and the number of grievances filed do not indicate wide-spread
dissatisfaction with RBHA services as rated by providers.
Provider satisfaction surveys could be expanded—The Division
may wish to proactively obtain feedback from providers regard-ing
quality of services provided by all five RBHAs. The Division
could administer the ten-question provider survey statewide to
measure RBHA services to providers. The Division should then
use the results of the survey to focus on RBHAs with low satis-faction
rates, because dissatisfaction could affect the quality of
behavioral health services clients receive. Further, because the
Division is dependent on RBHAs and providers to ensure there
is an adequate network in place to provide behavioral health
services to clients, the relationship between RBHAs and provid-ers
is important to the Division.
Division may wish to
survey providers of all
five RBHAs.
Finding II
22
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. The Division should continue its efforts to develop service-planning
guidelines for additional behavioral health diagno-ses.
2. The Division should consistently use its newly developed
uniform definitions for service availability performance
measures.
3. The Division should work to improve the response rate for
its consumer survey by considering alternative survey ad-ministration
methods, instead of relying on mail surveys.
4. The Division should consider expanding its survey of pro-viders
regarding their satisfaction with RBHA performance
to include all RBHAs.
OFFICE OF THE AUDITOR GENERAL
Appendix
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-i
Report name and description Frequency Preparer Recipient
Primary Source of
Requirememts
System-wide service appropriateness, delivery, and quality
reports. Enable recipients to monitor key aspects of service
delivery and system-wide operations.
1 Annual Report
Financial and programmatic report summarizing revenues
and expenditures, administrative costs, State Hospital
average daily census, accomplishments, and number of
people served by category.
Annually BHS Governor,
President of
Senate, and
Speaker of the
House of
Representatives
State Law
A.R.S §36-3405(A)(B)
2* Case File Review Report
RBHA staff review of Title XIX/XXI client files to determine
compliance with requirements for timeliness,
appropriateness, coordination of services, and inclusion of
client and family in service planning.
Annually RBHA BHS Federal Law
42 C.F.R. §434.53
3 Community Mental Health Services Performance Partnership
Block Grant Report Behavioral health system achievements,
problems with action plans, goals with measures, and
indicators.
Annually BHS Federal
SAMHSA
Grant
Performance Partnership
Block Grant
4 HB2003 Implementation Report
Progress report on mental health services funded by tobacco
litigation settlement monies.
Semi-
Annually
RBHA BHS State Law
Laws 2000,
Chapter 2, §1
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-ii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
5* Independent Quality Evaluation/Audit
Report from contracted specialist on services to clients.
Study based on provider case file review for particular
member group and can include interviews with key RBHA
staff.
Annually BHS AHCCCS Federal Law
45 C.F.R. §96-136
6 Medical Care Evaluation Study Results
Title XIX Level I inpatient and residential treatment centers’
report on results of their analysis of admissions, duration of
stay, and services. Includes recommendations for change, if
appropriate.
Annually Provider RBHA Federal Law
42 C.F.R. §456.141-145,
§456.241-245
7 Member Survey
Report on plan, implementation, and results of a client
satisfaction survey.
Biennially RBHA
BHS
BHS
AHCCCS
Federal Law
SSA §1932
8 Operational and Financial Review of the RBHAs
Includes financial reporting systems, and appropriateness of
service level determinations, congruence of services
authorized with level of care criteria and prior authorization
policy, appropriateness of case management services.
Annually RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §434.6, §434.50
9 Prevention Evaluation Report
Describes programs intended to prevent problems such as
substance abuse, domestic violence, school dropout, teen
pregnancy, and other problems. Includes program goals
and results.
Annually RBHA BHS Grant
Federal Substance Abuse
and Treatment (SAPT)
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-iii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
10 Quality Management/Utilization Management Plan (also called
Performance Improvement Plan)
Report on system to monitor RBHA compliance with
requirements in clinical care and administrative functions,
with progress on goals and objectives set in prior year’s
plan.
Annually BHS AHCCCS Federal Law
42 C.F.R. §456.6, §482.21,
§434.34, §456.100 et. seq.,
§456.200 et. seq.
11 Quality Management Report
Performance indicators and action plans for addressing
problems. Includes penetration rates, first service within 30
days of referral, symptomatic and health status outcomes,
inpatient days per thousand, average length of inpatient
stay, and trends in grievances.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §434.6, §434.34
12 Waiting Lists
Clients waiting for specified substance abuse services. Some
RBHAs also maintain for certain residential services.
Quarterly
or monthly
Provider
RBHA
RBHA
BHS
Grant
Federal SAPT
(Substance Abuse
Prevention and
Treatment)
13 Vocational Plan
Plan for increasing satisfactory employment of clients with
serious mental illness.
Annually RBHA BHS Contract
BHS/RBHA
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-iv
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
Program and project-specific reports. Enable stakeholders to
monitor specific programs and projects.
14 Annual Action Plan/Report
Plans and progress in meeting terms and conditions of the
J.K. Lawsuit Settlement Agreement.
Annually
(begins
11/01)
BHS and
AHCCCS
J.K. Lawsuit
defendants
Judicial
J.K. v. Eden settlement
agreement
15 Arizona Substance Abuse Treatment Needs Assessment
Substance use problems, treatment needs, and treatment
programs. BHS contracts with a variety of researchers,
including the University of Arizona Rural Health office, to
conduct the studies.
Annually BHS and
various
contracted
researchers
Federal
SAMSHA
Grant
Federal, State Substance
Abuse Needs Assessment
program
16 Arnold vs. Sarn Case File Reviews
Plans and progress in meeting terms and conditions of the
Arnold v. Sarn exit stipulation
Annually Value Op-tions/
BHS
Court
monitor
Judicial
Arnold v. Sarn exit
stipulation
17 Compulsive Gambling Treatment Program Report
Expenditures, services provided, and number of people
served through hotline and other services for compulsive
gamblers.
Quarterly BHS Lottery Contract:
Lottery/BHS
18 Correctional Officer/Offender Liaison Program Report
Substance abuse services for offenders released to
community supervision.
Quarterly RBHA BHS Contract
Department of
Corrections/BHS
19 Evaluation of Housing Approaches for the Seriously Mentally Ill
Evaluation of three approaches to housing people with a
serious mental illness: Supported housing, supportive
communities, and supervised apartments. BHS contracts
with three researchers, including Arizona State University,
to conduct the evaluations.
Once only,
at end of
project
(approx.
12/01)
BHS and
various
contracted
researchers
Federal
SAMHSA
Grant
Federal Supported
Housing Grant
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-v
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
20 Incentive Program Pilot
Survey results from clients, providers, and referring
agencies regarding RBHA performance. Used for
distributing incentive monies. Applies only to PGBHA.
Three times
per year
BHS Representative
Huppenthal
State Law
Laws 1994, Chapter 1, §24
21 Integrated Treatment Consensus Panel Evaluation
Evaluation of project to improve treatment of persons with
co-occurring mental health and substance abuse disorders.
Once only,
at end of
project
(1/31/02)
BHS and
University
of Arizona
Federal
SAMHSA
Grant
Federal Phase II
Community Action Grant
22 Inventory of Substance Abuse Prevention and Treatment
Programs
Program names/locations, funding, clients served
(number/demographics/problems), summary of services
provided, and evaluation of results achieved.
Annually Arizona
Drug &
Gang
Prevention
Resource
Center
(using
information
provided by
RBHAs)
Governor,
President of
the Senate,
Speaker of
the House
of
Representa-tives
State Law
A.R.S. §36-2023(c)
23 Mental Health Statistics Improvement Project (MHSIP) Report
Results of using common performance indicators with 15
other states in pilot project. Indicators incorporated into
BHS’ member survey.
Once only
at end of
project,
(7/1/02)
BHS Federal
Center for
Mental
Health
Services
(CMHS)
Grant
Federal MHSIP
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-vi
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
24 Project to Assist in Transition from Homelessness (PATH)
Report
Value Options, NARBHA, and CPSA only. Services and
clients served in program for homeless people with serious
mental illness; includes placements in housing.
Monthly
Annually
Provider
RBHA
BHS
RBHA
BHS
PATH
Grant
Federal PATH
25 Project MATCH (Multi-Agency Team for Children) Report
Accomplishments, services, and people served in a Pima
County program intended to provide an integrated system
of care for seriously emotionally disturbed children and
their families.
Quarterly BHS Federal
SAMHSA
Grant
Federal
SAMHSA
26 Status Report on the Terms and Conditions of the Exit Stipulation
For facilitating discussion in meetings with plaintiffs in
Arnold v. Sarn lawsuit. Includes update on strategic plans
for four areas, identified in a supplemental agreement to the
exit stipulation.
Three times
per year
BHS Court
monitor
and Arnold
v. Sarn
plaintiffs
Judicial
Arnold v. Sarn
Court monitor
27 Substance Abuse Prevention and Treatment (SAPT) Block Grant Report
Expenditures and services provided with the Block Grant
monies.
Annually BHS Federal
SAMHSA
Grant
Federal SAPT
Block Grant
Client protection reports. Enable report recipients to monitor
compliance with requirements related to client rights, safety, and
welfare.
28 Grievances and Appeals Report
Number and types of appeals and grievances filed by
members, providers, and RBHAs.
Quarterly Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §434.63
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-vii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
29 Incident and Accident Report
Summary of reported accidents, deaths, and incidents
including physical and sexual abuse.
Quarterly Provider RBHA Federal Law
42 C.F.R. §455.13
30 Incidents of Potential Fraud or Abuse
Observation and circumstances.
Upon
occurrence
RBHA
BHS
BHS
AHCCCS
State Law
A.R.S. §36-2918.01
31* Involuntary Commitment Report
Treatment plan and discharge summary for individuals
involuntarily committed to treatment by a Local Alcoholism
Reception Center (LARC) director’s petition.
Upon
occurrence
LARC BHS State Law
A.R.S. §36-2026.02(C)
32 Seriously Mentally Ill Client Mortality Report
Circumstances of death of client with serious mental illness.
Upon
occurrence
RBHA BHS State Regulation
Arizona Administrative
Code R9-21-409
33 Seriously Mentally Ill Client Seclusion and Restraints
Reports use of seclusion or restraints to manage client
behavior.
Monthly Provider RBHA State Regulation
Arizona Administrative
Code R9-21-204.(R)
34 Showing Report
Physician certifying need for Level I inpatient and
residential treatment center care.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §456.160
Provider network reports. Enable report recipients to monitor
service availability statewide.
35* Provider Affiliation Tape (also called Provider Network File)
Data for electronic matching of provider network
information between BHS and AHCCCS.
Monthly BHS AHCCCS Contract
AHCCCS/BHS
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-viii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
36 Provider Network Status Report (also called Provider Network
Evaluation and Sufficiency Report)
Narrative analysis of provider network sufficiency and list
of providers by geographic service area and type of service.
Annually RBHA
BHS
BHS
AHCCCS
Federal Law
SSA §1932
37 Provider Network Status Update/Report
Lists providers added and deleted, and changes in facilities’
licensure. Identifies material gaps in the provider network
and status of any corrective actions, including progress on
using technologies such as mapping software and
telemedicine.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
SSA §1932
38 Unexpected Changes That Could Impair the Provider Network
Provider termination, suspension, or failure to meet
licensing criteria.
Upon
occurrence
RBHA BHS Federal Law
SSA §1932
Service authorization and provision reports. Enable recipients
to monitor quantity and dollar value of services provided and
compliance with contractual stipulations defining who can
provide and receive services.
39 Encounter Reporting
Client services reported electronically from providers
through RBHAs and through BHS to AHCCCS. Encounter
data is used to set capitation rates and evaluate quality of
care.
Monthly Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-ix
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
Financial reports. Enable report recipients to monitor
contractor’s financial soundness and compliance with restrictions
on use of state and federal monies.
40 25th of the Month
Compares total expenditures for the month and year to date
as compared to prior years’ totals. Must also include
potential shortfalls in programs and potential federal and
other funds.
Monthly BHS Selected
legislators
and staff1
State Law
Laws 2001, Chapter 232,
§12
41 Budget
Budgeted schedule of revenues and expenses, required by
some RBHAs.
Annually Provider RBHA Contract
RBHA/Provider
42* Cost Allocation Plan
Defines direct and administrative costs and describes the
RBHA’s allocation methodology.
Annually RBHA BHS Federal Law
45 C.F.R. §95.501
Subpart E
43 Disclosure Statements
Ownership, related party transactions, creditors, board
members, key managers, and subcontractors.
Annually RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §455.100,
§1002.3,
§1124, §1128(a),
§1902(a)38
1 President of the Senate, Speaker of the House of Representatives, Chairmen of the Senate and House Appropriations Committees, and the Director of the Joint
Legislative Budget Committee.
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-x
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
44 Division Monthly Report
Shows Title XIX and non-Title XIX funding, administrative
and case management expenses, persons served, and units
of service by RBHA.
Monthly BHS Governor,
House
Speaker,
Senate
President
State Law
A.R.S.§36-3405(D)
45 Federal Financial Participation Reimbursement
Estimated cash requirements for outreach (ends 12/01)
Bi-weekly BHS AHCCCS Federal Law
Cash Management
Improvement Act
(CMIA) of 1990 (Public
Law 101-453) as
amended by CMIA of
1992 (Public Law 102-
589)
46 Financial Viability Ratios Statement
Ratios used for evaluating a RBHA’s financial condition.
Annually BHS AHCCCS Federal Law
42-C.F.R. §433.32, §434.50
47 Incurred But Not Reported Claims (also called Lag Report)
Costs associated with health care services incurred during a
financial reporting period but not reported to the prepaid
health care provider until after the reporting date.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32
48* Medications Report
Spending for psychotropic medications, and related client
and prescription counts.
Quarterly
Annually
RBHA BHS State Law
Laws 1998, Chapter 2, §8
and Laws 1999, Chapter
6, §5
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-xi
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
49* Non-Title XIX/XXI Children’s Behavioral Health Services
Summary (also called Grace Report)
Shows how money appropriated for children’s behavioral
health services is actually spent.
Monthly RBHA
BHS
BHS
Legislature
State Law
Laws 2001, Chapter 232,
§12
50 Notice of Real Property Transactions
Property purchase or sale notification.
Upon
Occurrence
RBHA BHS Contract
BHS/RBHA
51 Quarterly Expenditure Reports
Actual and projected administrative expenditures for
outreach activities (ends 12/31/01)
Quarterly BHS AHCCCS Federal Law
42 C.F.R. §433.32, §434.50
52 Schedule of Deferred Revenue
Revenues received but not yet earned, including the source
and use of the revenue.
Monthly RBHA BHS Contract
BHS/RBHA
53 Single Audit: Audited Financial Statements (draft and final)
Statement of financial position, statement of activities with
changes in net assets, statement of cash flows, functional
statement of expenses, and notes.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
54 Single Audit: OMB Circular A-133 Reports
Auditors’ reports on federal grant funding and compliance.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-xii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
55 Single Audit: Restated Fourth Quarter Statement of Activities
and Changes in Net Assets
Explains differences between year-end and audited
statement of activities based on auditor adjustments.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
56 Single Audit: Statement of Financial Position Reconciliation
Explains differences between year-end and audited financial
statements based on auditor adjustments.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
57 Statement of Activities
Shows year-to-date revenue and expenses for Title XIX/XXI
and non-Title XIX/XXI. Quarterly report also includes
changes in net assets.
Quarterly;
monthly
from RBHA
Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Contract
AHCCCS/BHS
58 Statement of Cash Flows
Provides information about cash inflows and outflows
during the period.
Quarterly;
monthly
from RBHA
Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32, §434.50
59 Statement of Financial Position
Illustrates the financial position in balance sheet format.
Quarterly;
plus
monthly
from RBHA
Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32, §434.50
60 Summaries of RBHA Financial Information
Summary reports; includes financial statements viability
ratio analysis, and analysis and review.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32, §434.50
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-xiii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
61* Tobacco Tax Cash Activity Statement
Cash flow of tobacco tax monies year-to-date. Includes
beginning cash balance, cash received, and cash disbursed.
Quarterly RBHA BHS Contract
BHS/RBHA
62 Tobacco Tax Evaluations Report
Use of monies allocated by A.R.S. §36-2921 for behavioral
health service program established in A.R.S. §36-3414.
Annually BHS JLBC State Law
A.R.S. §36-2907.071
63* Tobacco Tax Revenues and Expenditures Report
Revenues and expenditures of tobacco tax monies on an
accrual basis.
Quarterly RBHA BHS Contract
BHS/RBHA
1 In 2001, Senate Bill 1313 amended A.R.S. §36-2907.07, changing reporting requirements for tobacco tax evaluations beginning on July 1, 2002. The Auditor
General is to evaluate and report on tobacco tax programs administered by the Department of Health Services, with the first report due on November 15,
2004.
OFFICE OF THE AUDITOR GENERAL
Agency Response
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
Debra K. Davenport
Auditor General
2910 N. 44th Street
Phoenix, Arizona 85008
Dear Ms. Davenport:
Thank you for an opportunity to respond to your office's review of the behavioral health
system's reporting requirements.
We agree with the report and plan to implement all of its recommendations. We
commend the audit team for developing a thorough understanding of our reporting
requirements, our performance measurement system, and our quality improvement
efforts.
Once again, thank you for your professionalism and your fair and thorough evaluation.
Sincerely,
Catherine R. Eden
Director
Other Performance Audit Reports Issued Within
the Last 12 Months
01-10
Future Performance Audit Reports
Arizona State Lottery Commission
Arizona Health Care Cost Containment System
01-1 Department of Economic Security—
Child Support Enforcement
01-2 Department of Economic Security—
Healthy Families Program
01-3 Arizona Department of Public
Safety—Drug Abuse Resistance
Education (D.A.R.E.) Program
01-4 Arizona Department of
Corrections—Human Resources
Management
01-5 Arizona Department of Public
Safety—Telecommunications
Bureau
01-6 Board of Osteopathic Examiners in
Medicine and Surgery
01-7 Arizona Department
of Corrections—Support Services
01-8 Arizona Game and Fish Commission
and Department—Wildlife
Management Program
01-9 Arizona Game and Fish
Commission—Heritage Fund
01-10 Department of Public Safety—
Licensing Bureau
01-11 Arizona Commission on the Arts
01-12 Board of Chiropractic Examiners
01-13 Arizona Department of
Corrections—Private Prisons
01-14 Arizona Automobile Theft
Authority
01-15 Department of Real Estate
01-16 Department of Veterans’ Services
Arizona State Veteran Home,
Veterans’ Conservatorship/
Guardianship Program, and
Veterans’ Services Program
01-17 Arizona Board of Dispensing
Opticians
01-18 Arizona Department of Correct-ions—
Administrative Services
and Information Technology
01-19 Arizona Department of Education—
Early Childhood Block Grant
01-20 Department of Public Safety—
Highway Patrol
01-21 Board of Nursing
01-22 Department of Public Safety—
Criminal Investigations Division
01-23 Department of Building and
Fire Safety
01-24 Arizona Veterans’ Service
Advisory Commission
01-25 Department of Corrections—
Arizona Correctional Industries
01-26 Department of Corrections—
Sunset Factors
01-27 Board of Regents
01-28 Department of Public Safety—
Criminal Information Services
Bureau, Access Integrity Unit, and
Fingerprint Identification Bureau
01-29 Department of Public Safety—
Sunset Factors
01-30 Family Builders Program
01-31 Perinatal Substance Abuse
Pilot Program
01-32 Homeless Youth Intervention
Program

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State of Arizona
Office
of the
Auditor General
PERFORMANCE AUDIT
DIVISION OF BEHAVIORAL
HEALTH SERVICES—
Reporting Requirements
Report to the Arizona Legislature
By Debra K. Davenport
Auditor General
DEPARTMENT
OF
HEALTH SERVICES
December 2001
Report No. 01-33
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee
composed of five senators and five representatives. Her mission is to provide independent and impar-tial
information and specific recommendations to improve the operations of state and local government
entities. To this end, she provides financial audits and accounting services to the state and political
subdivisions and performance audits of state agencies and the programs they administer.
The Joint Legislative Audit Committee
Senator Ken Bennett, Chairman
Representative Roberta L. Voss, Vice-Chairman
Senator Herb Guenther Representative Robert Blendu
Senator Dean Martin Representative Gabrielle Giffords
Senator Peter Rios Representative Barbara Leff
Senator Tom Smith Representative James Sedillo
Senator Randall Gnant (ex-officio) Representative James Weiers (ex-officio)
Audit Staff
Shan Hays—Manager
and Contact Person (602) 553-0333
Angelica Gonzalez—Team Leader
Kirk Jaeger—Team Member
Kristie Waldron—Team Member
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
(602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553 -0333 • FAX (602) 553-0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
December 10, 2001
Members of the Arizona Legislature
The Honorable Jane Dee Hull, Governor
Dr. Catherine R. Eden, Director
Department of Health Services
Transmitted herewith is a report of the Auditor General, a review of the reporting
requirements in Arizona’s behavioral health system. This report is in response to Laws 2001,
Chapter 195, §1 which directed this Office to identify any duplicative or outdated reporting
requirements, look for ways to streamline reports, and consider criteria that measure the
performance of the Division of Behavioral Health Services (Division) in the Department of
Health Services. I am also transmitting with this report a copy of the Report Highlights for
this review to provide a quick summary for your convenience.
As outlined in its response, the Department of Health Services agrees with all of the findings
and recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on December 11, 2001.
Sincerely,
Debra K. Davenport
Auditor General
Enclosure
i
OFFICE OF THE AUDITOR GENERAL
SUMMARY
The Office of the Auditor General has conducted a review of the
reporting requirements in Arizona’s behavioral health system.
Laws 2001, Chapter 195, §1 directed the Office to identify any
duplicative or outdated reporting requirements, look for ways to
streamline reports, and consider criteria that measure the per-formance
of the Division of Behavioral Health Services (Division)
in the Department of Health Services.
The Division, its contracted Regional Behavioral Health Authori-ties
(RBHAs), and their contracted providers prepare reports to
meet legal, contractual, and judicial requirements. In total, audi-tors
identified 63 reports prepared by these organizations. The
reports enable the Division and its funding organizations, in-cluding
the Arizona Health Care Cost Containment System
(AHCCCS), to monitor essential aspects of system performance
such as service quality, client protection, continued availability of
services, and financial accountability.
The Division Can Streamline
Some Reports and
Eliminate Others
(See pages 5 through 13)
Although most of the 63 reports are necessary to oversee the be-havioral
health system and qualify to receive federal monies, the
Division recently combined 2 reports and can eliminate 6 others
without compromising oversight of the behavioral health system
or losing federal funding. In addition, it can make other im-provements
to simplify reporting. Combining two costly and
time-consuming case file reviews, and their associated reports,
should satisfy federal requirements while reducing the burden
on RBHAs and service providers. One of these reviews, called
the Independent Quality Evaluation, entailed hiring an inde-pendent
reviewer to examine a sample of cases for a specific
population, such as substance-abusing pregnant women, or
The Division can elimi-nate
six reports.
Summary
ii
OFFICE OF THE AUDITOR GENERAL
people with schizophrenia. The other review, called the Medi-caid
Case File Review, involved review by RBHA staff of a sam-ple
of Medicaid client files for compliance with federal regula-tions.
The Division and AHCCCS combined these two reviews
through a contract amendment effective October 3, 2001.
Six additional reports can potentially be eliminated, including
three outdated reports that were originally established by the
Legislature. The reports that may be eliminated are:
¾ Three financial and claims reports that are duplicative or un-necessary,
including two reports on the use of tobacco tax
monies.
¾ A report requested by a former legislator to monitor shifts of
appropriated monies. Such shifts can no longer occur due to
a law passed in 2000.
¾ A report established to monitor spending of a special appro-priation.
This requirement in an appropriation footnote has
ended.
¾ A report based on an involuntary commitment statute for
chronic alcoholics. No such commitments have occurred in
recent years, so no report has been prepared. The Legislature
should consider reviewing and revising the statute and then,
if appropriate, eliminating the associated report.
However, three other reports related to settlements on two class-action
lawsuits appear necessary to demonstrate progress to-ward
meeting the lawsuit settlement agreements. These reports
cannot be eliminated or streamlined until the court and plaintiffs
are satisfied with the State’s performance.
Finally, the Division could simplify reporting if it can improve
the data entry process for its two databases. Specifically, it
should continue its efforts to enable the RBHAs to send data re-cords
only once, instead of sending them separately to both da-tabases.
Summary
iii
OFFICE OF THE AUDITOR GENERAL
Division Can Continue To
Improve Performance
Measurement in Four Key Areas
(See pages 15 through 22)
The Division measures performance in all four areas auditors
were directed to consider, although performance measurement
can be improved in each area. First, the Division measures clini-cal
quality in several ways, including case file reviews and a va-riety
of other oversight activities. It should continue its progress
in developing service-planning guidelines that identify best prac-tices
for specific client diagnoses. Second, the Division measures
service availability, using provider network reports, waiting list
information, and reports on the length of time clients wait to re-ceive
services. However, it has only recently developed uniform
definitions for some service availability performance measures. It
should use these new measures consistently in the future. Third,
the Division measures quality of service as rated by the patient or
the patient’s family, primarily through a Statewide Consumer
Perception Survey administered by mail. However, this meas-urement
is hampered by low survey responses. The Division
should use alternative survey administration methods in order
to obtain more meaningful results.
Finally, the Division currently measures the fourth area, quality
of RBHA services as rated by providers, for only one of the five
RBHAs. This measurement is part of the Incentive Pilot Program
established in 1994. Although provider dissatisfaction with
RBHA services does not appear to be widespread, the Division
should consider surveying providers statewide in order to iden-tify
and address any problems. The relationship between RBHAs
and providers is important because the Division relies on both to
deliver services to clients, and unresolved dissatisfaction might
affect the quality of behavioral health services clients receive.
The Division measures
clinical quality in several
ways.
iv
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
v
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS
Page
Introduction and Background....................... 1
Finding I: The Division Can
Streamline Some Reports
and Eliminate Others................................. 5
Two Costly and Time-Consuming
Case File Reviews and Reports
Were Recently Combined.......................................... 5
Six Reports Can
Be Eliminated .............................................................. 7
Reports Related To Judgments
on Class-Action Lawsuits
Are Still Needed.......................................................... 10
Procedural Improvement
Could Simplify Reporting.......................................... 11
Recommendations...................................................... 13
Finding II: Division Can Continue
To Improve Performance
Measurement in Four Key Areas............. 15
Clinical Quality Measured
in Several Ways but Measurement
Can Be Improved........................................................ 15
Division Is Making Progress in
Measuring Service Availability ................................. 17
Table of Contents
vi
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS (Concl’d)
Page
Finding II: (Concl’d)
Quality-of-Service Ratings
Are Hampered by
Low Survey Responses .............................................. 18
RBHA Services Rated by
Providers for Only One
of Five RBHAs............................................................. 20
Recommendations...................................................... 22
Appendix.......................................................... a-i
Agency Response
1
OFFICE OF THE AUDITOR GENERAL
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a review of the
reporting requirements in Arizona’s behavioral health system.
Laws 2001, Chapter 195, §1 directed the Office to identify any
duplicative or outdated reporting requirements, look for ways to
streamline reporting, and consider criteria that measure the Divi-sion’s
performance.
Arizona’s behavioral health system is administered by the De-partment
of Health Services’ Division of Behavioral Health Ser-vices
(Division), which provides publicly funded mental health
services and substance abuse treatment and prevention services.
According to the Division, in fiscal year 2001, the Division re-ceived
approximately $389 million, including about $199 million
in Title XIX (Medicaid) monies from the Arizona Health Care
Cost Containment System (AHCCCS) and $39.2 million in non-
Title XIX federal monies. All but approximately $15.5 million
was allocated among five contracted Regional Behavioral Health
Authorities (RBHAs), which operate like health maintenance or-ganizations
to coordinate services in their geographic regions.
The RBHAs contract with a network of more than 350 service
providers to offer a broad range of behavioral health services to
over 100,000 consumers throughout the State.
Sources of Reporting
Requirements
Each organization in the behavioral health system, including the
Division, the RBHAs, and the service providers, prepares reports
to meet contractual, legislative, and judicial requirements. The
Appendix (see pages a-i through a-xiii) lists 63 required reports
and the primary sources establishing the requirements. The three
main sources of reports are:
¾ State and Federal Requirements—Forty of the 63 reports
are prepared in response to state and federal laws and regu-lations.
Arizona laws and regulations establish require-
Sixty-three reports origi-nate
from contractual re-quirements,
legislative re-quests
or mandates, and
judicial mandates.
Introduction and Background
2
OFFICE OF THE AUDITOR GENERAL
ments for 13 of these 40 reports. For example, an Arizona
statute requires the Division to submit monthly reports on
expenditures, persons served, and units of service. Federal
laws and regulations, including those governing the use of
Medicaid, establish the other 27 of the 40 reporting require-ments.
¾ Contractual/Grant Requirements—Twenty additional re-ports
are required by contracts or grants. The primary
sources for 10 reports are contracts between AHCCCS, the
Division, the RBHAs, and the providers. For example, the
Division’s contracts with the RBHAs and the RBHAs’ con-tracts
with their providers establish reports to monitor spend-ing,
services, and compliance with state laws, and to gather
information needed for the Division’s reports to AHCCCS.
The primary sources for the remaining ten reports are grants
from the federal government, which include reporting re-quirements
as a condition of receiving grant monies. Cur-rently,
the Division, RBHAs, and providers have grants from
several federal programs. The majority of these grants are
funded by the Substance Abuse and Mental Health Services
Administration (SAMHSA), a federal agency within the De-partment
of Health and Human Services.
¾ Judicial Requirements—Finally, judicial requirements dic-tate
the preparation of three reports. One report and a case
file review are prepared as a result of the Arnold v. Sarn law-suit.
1 The Division prepares these items to show progress
toward meeting the criteria for exiting the lawsuit. Beginning
in November 2001, a more recent lawsuit settlement, J.K. v.
Eden, will also require a report.2
1 In 1981, the Superior Court of Arizona found that the Department of
Health Services did not provide the level of services promised in state law
to seriously mentally ill persons in Maricopa County. An agreement nego-tiated
with the plaintiffs in 1995 establishes criteria for exiting the lawsuit,
and until those criteria are met, a court-appointed monitor oversees com-pliance
with the court-ordered agreement.
2 The Division and AHCCCS entered into a settlement in 2001 to resolve a
10-year-old lawsuit filed on behalf of AHCCCS-eligible children who need
mental health services. The agreement is based on a set of principles that
stress family involvement and collaboration among agencies.
Introduction and Background
3
OFFICE OF THE AUDITOR GENERAL
Purposes of
Reporting
Collectively, the behavioral health system reports serve as moni-toring
tools for the Division and its funding organizations, includ-ing
AHCCCS and the federal government. Oversight of the be-havioral
health system is critical to ensure that clients receive
needed, quality services. Reporting on availability and quality of
services is particularly important under Arizona’s system because
RBHAs receive payment in advance, based on a capitated rate per
Medicaid-eligible person, instead of receiving payment for ser-vices
once they have been delivered. This approach can help con-trol
costs, but may also give RBHAs an incentive to keep their
own costs down by limiting care. As indicated in a 1999 perform-ance
audit of the Division (Auditor General Report No. 99-12), the
Division has made substantial efforts to improve oversight com-pared
to previous audits, including improving the way it moni-tors
RBHA performance through required reports. Behavioral
health system reports enable oversight of several essential aspects
of contractor performance:
¾ Service to clients, including appropriateness based on the
client’s diagnosis, timeliness of services, use of appropriate
assessments, treatment planning, treatment delivery by
qualified individuals, and client and family satisfaction with
services;
¾ Client outcomes, measured using clinical scores that show
changes in client condition; for example, decreased substance
abuse, as well as client and family satisfaction with outcomes,
and mortality rates;
¾ Client protection, including monitoring client rights, treat-ing
clients in the least restrictive environment possible, and
addressing grievances, appeals, and incidents of fraud or
abuse appropriately;
¾ Continued availability of services, measured by adequacy
of the existing provider network in offering services in geo-graphic
areas, as well as by contractors’ financial viability; and
Oversight of the behav-ioral
health system is
critical to ensure that
clients receive needed,
quality services.
Introduction and Background
4
OFFICE OF THE AUDITOR GENERAL
¾ Financial accountability, including compliance with restric-tions
on the use of state and federal monies.
Scope and Methodology
This review addresses the following purposes identified in Laws
2001, Chapter 195, §1 regarding behavioral health system re-ports:
¾ To identify duplicative and outdated reporting requirements
and recommend ways that the reporting requirements can be
streamlined into a more meaningful format.
¾ To consider criteria that measure the Division’s performance,
including clinical quality, availability of services, quality of
service as rated by the patient or patient’s family, and quality
of RBHA services as rated by service providers.
To address these issues, auditors reviewed reporting require-ments
established in contracts, legislation, and court decisions;
interviewed Division, RBHA, and provider staff to identify other
reports they prepare; examined and compared reports to their
reporting requirements; and interviewed report recipients about
the way they use the reports and the effect of eliminating or
streamlining the reports.
This report contains recommendations in two areas:
¾ The Division can streamline some reports and eliminate oth-ers.
¾ The Division can continue to improve performance meas-urement
in four key areas.
The report also includes an Appendix (see pages a-i through a-xiii)
that lists 63 reports required by the behavioral health system.
The Auditor General and staff express appreciation to the Direc-tor
of the Department of Health Services, the Deputy Director of
the Division of Behavioral Health Services, the RBHAs,
AHCCCS, and their staff for their cooperation and assistance
throughout the review.
5
OFFICE OF THE AUDITOR GENERAL
FINDING I THE DIVISION CAN
STREAMLINE SOME REPORTS
AND ELIMINATE OTHERS
The Division has the opportunity to combine some reports and
eliminate others without compromising oversight of the behav-ioral
health system. Two of the 63 reports currently produced
were consolidated during the audit because they are essentially
similar, and 6 others can be eliminated because they are no
longer necessary. However, 3 reports prepared as a result of the
settlement of two class-action lawsuits cannot be combined or
eliminated until the court and plaintiffs are satisfied with the
State’s performance. Still, the Division can simplify and stream-line
processes for the remaining reports by eliminating the need
to enter data into two separate computer databases.
Two Costly and Time-Consuming
Case File Reviews and Reports
Were Recently Combined
Until October 3, 2001, the Division conducted two extensive but
similar case file reviews, with each review resulting in a separate
report covering such issues as quality and appropriateness of
care. Both examined large, statistically valid samples of client
files across all RBHAs, and both were conducted to satisfy fed-eral
mandates. Because the two reviews and reports had similar
purposes, included some of the same information, and relied on
some of the same case files, the reviews have been combined.
This should significantly reduce the reporting burden on RBHAs
and their providers. The two file reviews were as follows:
¾ Independent Quality Evaluation—This annual review was
conducted to satisfy a federal requirement. It evaluated qual-ity
of care for a selected client group or diagnosis by assess-ing
treatment approaches, comparing treatment provided
Combining two extensive
but similar case file reviews
will significantly reduce
the reporting burden.
Finding I
6
OFFICE OF THE AUDITOR GENERAL
against service-planning guidelines, and reviewing client
outcomes. A different client group or diagnosis was chosen
each year. For example, the review and report addressed
children in 1999, substance-abusing pregnant women in 2000,
and people with schizophrenia in 2001. Federal regulations
mandate that an independent reviewer conduct this review.
The Division spent approximately $350,000 per year on it, us-ing
administrative dollars provided by AHCCCS.
The review placed substantial demands on the RBHAs and
their providers. The provider file samples reviewed have
ranged from 122 to 1,689 total cases, depending on the topic.1
RBHAs and providers had to gather case files from all their
locations, prepare or copy them for review, and assist the
independent reviewers by answering questions and helping
set up meetings with key RBHA and provider staff. Given
the review’s size, this work was extensive. For example, in
2001, one provider reported spending 175 staff hours making
copies of client files for the independent reviewer.
¾ Medicaid Case File Review—This review, also conducted
annually to satisfy a federal mandate, assessed compliance
with federal requirements for Title XIX/XXI clients, includ-ing
timeliness of treatment, whether services are rendered by
providers with appropriate expertise, quality of care, and cli-ent
outcomes. A federal regulation allows qualified staff or
an independent evaluator to conduct this review. Using Divi-sion
records, auditors estimated that the 1999 review, con-ducted
by RBHA staff, cost approximately $75,000.2
1 For the 2001 evaluation, AHCCCS and the Division initially agreed on a
sample size of 2,371 client files. In order to reduce the burden on provid-ers,
the sample size was reduced to 1,689 before the evaluation was con-ducted.
2 Auditors calculated this figure using 1999 Arizona Community Behavioral
Health Wages information for clinically qualified staff and BHS staff esti-mates
of time spent reviewing case files. Source: Information provided by
the Division, using 4th Quarter 1999 State Occupational Employment-Arizona
and Wage Estimates and 4th Quarter 1999 National Occupational Employment
and Wage Estimates.
Finding I
7
OFFICE OF THE AUDITOR GENERAL
Like the Independent Quality Evaluation, this review placed
demands on both RBHAs and providers. The 1999 review
examined 1,189 case files. In addition to gathering and pre-paring
the files for review, the RBHAs supplied qualified
staff who conducted the reviews using a 94-question Quality
of Care Case File Instrument.
The Division and AHCCCS began discussing the potential for
combining the two reviews during the audit, and combined
them in an October 3, 2001, contract amendment. To meet federal
requirements, an independent evaluator will need to conduct the
combined review. An AHCCCS official believes a statistically
valid, independent review of a target population, including a re-view
of the factors currently assessed in the Medicaid case file
review, will satisfy both requirements. Because approximately 50
percent of the Division’s clients are not Title XIX/XXI eligible,
the Division will also need to ensure that these individuals are
included in the combined review.
Six Reports
Can Be Eliminated
Six of the behavioral health system’s 63 reports are no longer
necessary and can therefore be eliminated without affecting
oversight of behavioral health programs. Three of these six re-ports
are either not used at all or contain information that is
available in other reports. Two of the six are prepared in re-sponse
to earlier legislative mandates that are no longer applica-ble.
A sixth report pertains to a statutory provision that is out-dated
and has not been used in some time. In addition, the Divi-sion
should eliminate the annual reporting requirement for the
cost allocation plan and require reports only when the cost allo-cation
method changes.
Three financial and claim reports are duplicative or unneces-sary—
Three reports appear unnecessary because they duplicate
material in other reports or are not used at all. Although elimi-nating
any one of these reports would not result in substantial
time savings for any one provider or RBHA, the combined effect
could be significant. Each report requires preparation at more
than one level in the behavioral health system. Further, at the
The 1999 Medicaid Case
File Review examined
1,189 case files.
Three reports are not used
at all or contain informa-tion
that is available in
other reports.
Finding I
8
OFFICE OF THE AUDITOR GENERAL
RBHA and Division levels, the reports received from providers
and RBHAs are reviewed, combined, and submitted elsewhere.
The three reports are as follows:
¾ Provider Affiliation Tape (also called Provider Network
File)—The RBHAs and the Division use this report to submit
a list of authorized providers and identification numbers for
comparison with AHCCCS’ records. The Division and
AHCCCS recently agreed to replace it with a more efficient
online process for comparing the information. However, as of
October 3, 2001, the contract between AHCCCS and the Divi-sion
still requires this report.1
¾ Tobacco Tax Revenues and Expenditures Report—This
report, which the Division submits to the Department of
Health Services’ budget analyst, is not necessary. The report
explains how each RBHA uses monies from the tobacco tax;
however, the budget analyst uses a different report for this
purpose—the legislatively mandated Tobacco Tax Evalua-tions
Report.
¾ Tobacco Tax Cash Activity Report—Similar to the Tobacco
Tax Statement of Revenue and Expenses, RBHAs prepare
this report for the Department budget analyst, but the analyst
does not use it.
Three legislatively mandated reports no longer needed—In three
cases, reports prepared in response to legislative mandates can
be eliminated. Two of these reports are no longer needed be-cause
the mandate no longer applies. The third, which has not
been prepared in nearly 10 years, relates to a seldom-used pro-cedure
for involuntarily committing a chronic alcoholic for
treatment. The Legislature should consider reviewing the statute
that makes this report necessary.
1 The AHCCCS contract lists this item as two separate reports, a tape and a
file. However, according to the Division, the tape was the physical me-dium
for transmitting the file to AHCCCS. The Division now uses disks
instead of magnetic tapes for transferring computerized records, but the
contract was never modified to delete the reference to the tape.
Two reports are no
longer needed because
the mandate no longer
applies.
Finding I
9
OFFICE OF THE AUDITOR GENERAL
¾ Non-Title XIX/XXI Children’s Behavioral Health Services
Summary (also called Grace Report)—This report, origi-nally
requested by a former legislator to monitor whether
monies appropriated for non-Title XIX children were actually
used for such children, is no longer necessary. Laws 2000,
Chapter 2, §1 prohibits the Division from moving monies
from one budget line item to another, such as from non-Title
XIX children to other uses.
¾ Quarterly Medications Report—This report, prepared in
response to a 2-year legislative requirement that ended in
1999-2000, is no longer necessary. In 1998 and 1999, the Legis-lature
appropriated a total of over $16 million for psychotro-pic
medications, and required the Division to report on how
the monies were being used. This requirement in an appro-priation
footnote has since expired. The Division can con-tinue
to monitor spending on medications through its annual
medications report, without requiring RBHAs to submit this
quarterly report. Information on expenditures for psychotro-pic
medications can readily be gathered from the RBHA
computer systems as needed.
¾ Involuntary Commitment Report—Pursuant to A.R.S §36-
2026.01, the Director of the Local Alcoholism Reception Cen-ter
(LARC), located in Maricopa County, may petition the
court for involuntary commitment of a person deemed a
chronic alcoholic, and must submit a report to the Division
about such commitments. However, the current LARC pro-gram
manager has never petitioned the court for involuntary
treatment, and the Division has not received a report since
1992. Further, since the time this statute was enacted, deliv-ery
of behavioral health services, including alcoholism ser-vices,
changed. The County no longer has primary responsi-bility
for such services, and LARC is now operated by a pri-vate,
nonprofit organization. Additionally, involuntary
commitment is not consistent with best practices in substance
abuse treatment, and there are other ways of treating clients.
The Legislature should consider reviewing and revising the
involuntary commitment statute and eliminating the associ-ated
report, if appropriate.
The Legislature should
consider reviewing the
involuntary commit-ment
statute and the
associated report.
Finding I
10
OFFICE OF THE AUDITOR GENERAL
One financial report not needed annually—The Annual Cost Al-location
Plan, which the Division receives from each RBHA, de-fines
direct and administrative costs and describes the RBHA’s
allocation methodology. The AHCCCS contract with the Divi-sion
sets a limit on recovery of administrative costs at 8 percent
of the value of direct services provided. Further, such costs must
be allowable under the federal Office of Management and
Budget (OMB) Circular A-122. Currently, the Division requires
each RBHA to submit a plan every year. However, the Division
should work with AHCCCS to eliminate the annual requirement
for a complete report, and instead require reports only when the
plans change. If there have been no changes to their plans, the
RBHAs should be required to annually submit a statement that
the existing plan is not outdated.
In addition, the Division should improve its oversight of the
RBHAs by reviewing the plans. Currently, the Division does not
review the plans it receives. However, it should compare the
listed items against approved administrative costs identified by
the OMB Circular, and require the RBHAs to correct their plans
when needed.
Reports Related To
Judgments on Class-Action
Lawsuits Are Still Needed
Three of the 64 reports are related to settlements on two class-action
lawsuits. These reports appear necessary to demonstrate
progress toward meeting the lawsuit and settlement agreements
and cannot be eliminated or streamlined until the court and
plaintiffs are satisfied with the State’s performance. However,
the Division and the Maricopa County RBHA should work with
the court monitor to streamline the process for the lawsuit per-taining
to seriously mentally ill adults. The two suits and related
reports are as follows:
¾ Arnold v. Sarn—The 1995 agreement negotiated by the De-partment
of Health Services and the plaintiffs in the Arnold v.
Sarn lawsuit, which focused on the State’s obligation to seri-ously
mentally ill adults in Maricopa County, includes an
Reports on two class-action
lawsuits appear
necessary to demonstrate
progress until the court
and plaintiffs are satisfied
with the State’s perform-ance.
Finding I
11
OFFICE OF THE AUDITOR GENERAL
annual case review and a regular status report.1 The case re-view
is the primary tool used to demonstrate progress in
meeting the agreement obligations. Specially trained RBHA
staff conduct these reviews, answering 329 questions for each
case based on a review of the file and interviews with the cli-ent,
case manager, and other persons. Division staff certified
by the court monitor review the RBHA staff findings in a
process called case judging. Each of these reviews takes ap-proximately
3 full days to conduct, including the file review,
the interviews, writing the findings, and case judging.
In 1999, the Auditor General suggested the Division consider
having the court monitor conduct the case file reviews as part
of her independent review, since she retained the right to ne-gate
the Division’s findings and had done so in the past (Re-port
No. 99-12). The Division and the court monitor worked
together to develop the current procedure and training, and
hope this will result in agreement on the findings. The Divi-sion
and the court monitor should continue working together
to streamline the process. For example, they could eliminate
questions once the monitor is satisfied that the underlying
criteria have been addressed.
¾ J.K. v. Eden—Under the terms of the settlement in this case,
which addressed AHCCCS-eligible children who need men-tal
health services, the Division is required to prepare an an-nual
action plan describing strategies and activities relating to
agreed-upon obligations, such as statewide training and ex-panding
services for this population.2 In addition, in-depth
case reviews and interviews with family and relevant indi-viduals
in the child’s life are required.
Procedural Improvement
Could Simplify Reporting
In addition to streamlining or eliminating certain reports, the Di-vision
may be able to simplify reporting by improving the data
1 160 Ariz. 593; 775 P.2d 521; 1989, Maricopa County C-432355.
2 J.K. v. Eden, Arizona Federal District Court Case, No. CIV91-261.
Finding I
12
OFFICE OF THE AUDITOR GENERAL
entry process for the Division’s databases. The Division currently
requires RBHAs to enter information separately into two data-bases:
the Client Information System (CIS), which contains bill-ing
information; and the Client Enrollment, Disenrollment, and
Assessment Reporting (CEDAR) system, which contains client
information. Currently, RBHAs transmit partial client data re-cords
from their own computer systems to CIS. CIS assesses the
accuracy and completeness of the record as submitted, and sends
it back to the RBHA. The RBHA then adds demographic and
clinical data and submits the data record to CEDAR. Therefore,
the RBHAs must send each record twice. The Division has begun
exploring ways to enable the RBHAs to send data only once. Di-vision
officials hope to include an improved data entry process
with other changes that will be required by October 2002 to im-plement
the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), which mandates federal standards for comput-erized
systems.
Finding I
13
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. The Division should eliminate the following reports:
a) Provider Affiliation Tape (also called Provider Network File)
b) Tobacco Tax Revenues and Expenditures Report
c) Tobacco Tax Cash Activity Report
d) Non-Title XIX/XXI Children’s Behavioral Health Services
Summary (also called Grace Report)
e) Quarterly Medications Report
2. The Division should work with AHCCCS to eliminate the
annual requirement for the Cost Allocation Plan, and
a) Require reports only as needed when the plans change; and
b) Review the plans and compare them against approved admin-istrative
costs identified by Office of Management and Budget
Circular A-122 and require the RBHAs to correct their plans
when needed.
3. The Legislature should consider reviewing and revising the
involuntary commitment statute for chronic alcoholics in
A.R.S. §36-2026.01 and eliminating the associated report, if
appropriate.
4. The Division should continue working with the court moni-tor
to streamline the Arnold v. Sarn case file review.
5. The Division should continue its efforts to improve the data
entry process for the Client Information System (CIS) and
Client Enrollment, Disenrollment, and Assessment Reporting
(CEDAR) system databases.
14
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
15
OFFICE OF THE AUDITOR GENERAL
FINDING II DIVISION CAN CONTINUE TO
IMPROVE PERFORMANCE
MEASUREMENT IN
FOUR KEY AREAS
The Division measures performance in all four areas auditors
were directed to consider. Most measurement occurs for clinical
quality. The least amount of measurement is done of provider
satisfaction with RBHA services. However, measurement can be
improved in each area.
Laws 2001, Chapter 195, §1 instructed auditors to consider
whether the behavioral health system reports contain criteria that
measure the performance of the Division in the following areas:
¾ Clinical quality,
¾ Availability of services,
¾ Quality of service as rated by the patient or the patient’s fam-ily,
and
¾ Quality of regional behavioral health authority services as
rated by their service providers.
Clinical Quality Measured
in Several Ways but
Measurement Can Be Improved
The Division assesses clinical quality in several ways. However,
the Division should continue its efforts to develop a comprehen-sive
set of service-planning guidelines describing quality-of-care
standards.
Finding II
16
OFFICE OF THE AUDITOR GENERAL
Division has multiple mechanisms for
measuring clinical quality—The Divi-sion
measures clinical quality through
case file reviews. It recently combined
two separate reviews that examine as-pects
of clinical quality, such as whether
services are appropriate and delivered
by qualified providers. One of these re-views,
the Independent Quality Evalua-tion,
examines clinical quality measures using an evaluation tool
composed of quality standards particular to a certain population.
In addition, the Division measures clinical quality in the follow-ing
ways:
¾ Medical care evaluation studies, performed by certain pro-viders,
help to ensure that services are consistent with patient
needs and established health care standards.
¾ Through reports from RBHAs, Division staff examine the use
of client seclusion and physical restraints, and monitor
whether caregivers use the least restrictive method of treat-ment.
¾ Division staff assess the success of clinical treatment methods
by examining how long clients must stay in treatment, and
how often clients must be readmitted for additional treat-ment.
¾ The State’s participation in the Mental Health Statistics Im-provement
Program (MHSIP)1 provides benchmarks for ac-cess
to services, quality of services, appropriateness of ser-vices,
outcomes, and general satisfaction.
The Division uses this information to identify needed improve-ments
and develop plans to address any problems identified. For
example, the medical care evaluation and seclusion and restraint
1 The Mental Health Statistics Improvement Project (MHSIP) is a national
effort to develop benchmarks for mental health services. Arizona is 1 of 16
states participating in the development of these benchmarks under a grant
from the federal Substance Abuse and Mental Health Services Administra-tion.
The Division measures
clinical quality through
case file reviews.
Clinical Quality
Quality of services in
a treatment setting as
determined by ac-cepted
standards
and best practices.
Finding II
17
OFFICE OF THE AUDITOR GENERAL
measures are included in an annual Operational and Financial
Review the Division conducts at each RBHA. A Corrective Ac-tion
Plan is developed to address problem areas identified in this
review.
Division can continue to improve clinical quality assessment—
While the Division has a number of clinical quality measures,
some of them are not tied to a comprehensive set of service-planning
guidelines and best practices. A 1996 Auditor General
report (No. 96-19) recommended that the Division develop stan-dards
of care through service-planning guidelines across the
spectrum of needs it strives to meet. The Division has made pro-gress
in doing so. So far, it has guidelines for 15 client groups or
diagnoses, including substance-abusing pregnant women and
people with schizophrenia. It uses these guidelines to inform
providers and RBHAs of best practices, and to assess client
treatment plans in its case file reviews. However, there are many
other conditions patients are being treated for, such as bipolar
disorder, that currently lack guidelines. The Division needs to
continue its efforts to develop guidelines and standards for other
client diagnoses.
Division Is Making
Progress in Measuring
Service Availability
The Division addresses service availability in two primary ways.
First, it monitors how long it takes clients to receive services by
comparing referral dates to dates of first service, and works with
the RBHAs to develop corrective action plans for addressing
problems. Second, it assesses availability of services by geo-graphic
area, and monitors provider waiting lists for certain cli-ents
and certain types of services. It requires RBHAs to provide
this information in annual provider network reports. In these re-ports,
the RBHAs must identify what services are needed but
unavailable and propose plans to correct service gaps. The Divi-sion
is currently establishing a baseline of provider network ca-pacity,
and plans to take “snapshots” of network changes in an
automated quarterly report. As recommended in the 1999 per-formance
audit of the Division (Report No. 99-12), the Division is
using mapping software to help it assess the sufficiency of the
Network reports show
availability of services by
geographic area.
Finding II
18
OFFICE OF THE AUDITOR GENERAL
statewide provider network. Due to the passage of Proposition
204 in November 2000, which expanded eligibility for services,
analyzing the provider network is an especially important func-tion
at this time to ensure services are available for existing and
new clients. The Division should continue improving the as-sessment
of provider network availability.
Although the Division has made progress in measuring avail-ability,
the measures it uses have not been fully consistent. For
example, the Division only recently defined the term “enrolled,”
which caused some inconsistencies in calculating various per-formance
measures that rely on enrollment. One such measure is
penetration rate, which measures the number of clients enrolled
and served compared to the number of potential clients in the
population. This measure is an aspect of service availability,
since low penetration rates can indicate needed services are not
available. The Division recently developed a uniform definition
for this measure and other terms used to calculate it. The Divi-sion
should use the new definitions consistently and ensure that
it develops complete, uniform definitions when it adds or modi-fies
performance measures in the future.
Quality-of-Service Ratings
Are Hampered by Low
Survey Responses
The Division monitors quality of service as rated by the patient
or the patient’s family primarily through a survey sent to pa-tients
and their families. This is a useful instrument, particularly
because the results can be benchmarked with results from other
states, but low response rates from those surveyed diminish the
meaningfulness of Arizona’s results. The Division can take steps
to increase the response rate.
Consumer Perception Survey offers opportunity to benchmark
Arizona’s performance with other states—The primary meas-urement
tool addressing quality of service as rated by the patient
or the patient’s family is the Statewide Consumer Perception
Survey. The survey assesses client and family satisfaction with
services provided. Every 2 years, the Division and the RBHAs
survey clients. The survey instrument, available in both English
Survey assesses client
and family satisfaction in
four areas.
Finding II
19
OFFICE OF THE AUDITOR GENERAL
and Spanish, measures four areas of satisfaction: access to ser-vices,
quality and appropriateness of services, outcomes, and
general satisfaction. For example, in 1999, clients were asked to
indicate their levels of agreement or disagreement with 25 state-ments,
including:
Ø I like the services that I received here
Ø I was able to get all the services I thought I needed
Ø Staff returned my calls within 24 hours
Ø Staff told me what side effects to watch for
Ø As a result of services, I deal more effectively with daily
problems
Ø As a result of services, I do better in school and/or work
The survey includes questions drawn from the national Mental
Health Statistics Improvement Project (MHSIP), which will allow
the Division to benchmark itself against other states. The Divi-sion
sends survey results to MHSIP, produces a biennial report,
and submits survey results to the Arizona Master List of State
Government Programs to show consumer satisfaction rates.
Low response rate affects reliability of results—While the sur-vey
can provide useful information, the Division needs to im-prove
response rates in order to make the results more meaning-ful.
In 1999, the response rate was only 19 percent, making it im-possible
to generalize results statewide. The 2001 survey yielded
similar low response rates. Both surveys were conducted primar-ily
by mail, a method that often gives poor response rates. To
improve the response rate, the Division needs to consider alter-native
survey administration methods. The MHSIP project work
group is currently evaluating various methods, including face-to-
face interviews conducted by consumers. Other states have
reported response rates as high as 84 percent when using face-to-face
survey methods.
Consumer satisfaction also measured in other ways—In addi-tion
to the Consumer Perception Survey, client satisfaction is also
Division needs to im-prove
response rates by
using alternative sur-vey
administration
methods.
Finding II
20
OFFICE OF THE AUDITOR GENERAL
a factor in two case file reviews, which include interviews with
clients and family members. For example, beginning in Novem-ber
2001, as part of an annual action plan to satisfy J.K. v. Eden
settlement agreement stipulations, the Division will conduct pa-tient
and family interviews as well as case file reviews. This in-formation
will provide the Division additional perceptions of
families’ and children’s quality of care. Finally, one RBHA con-ducts
a consumer survey as part of its pilot incentive program.
RBHA Services Rated by
Providers for Only One
of Five RBHAs
In contrast to its efforts with regard to the three other types of
performance measures auditors were asked to address, the Divi-sion
does relatively little to gather information about the quality
of RBHA services as rated by the providers that contract with
each RBHA. The Division formally measures providers’ percep-tions
of quality at only one RBHA. The Division should consider
measuring such perceptions system-wide.
Provider satisfaction measurement of one RBHA is tied to in-centive
program—The measurement of providers’ satisfaction
with one RBHA is done as part of a pilot incentive program es-tablished
by Laws 1994, Chapter 1, §24.1 The pilot program pro-vides
financial incentives to the RBHA based on providers’ satis-faction
with the services the RBHA provides. For example, in
January 2001, the RBHA received $751 based on the results of a
provider satisfaction survey. Provider staff responded to ten
questions, such as, “Does the RBHA process claims and pay bills
on time?” and “Do you receive the technical assistance you need
from the RBHA?” The results show that provider satisfaction
1 The incentive program includes two other components besides provider
satisfaction. Specifically, both providers and the RBHA can earn incentive
payments based on the results of client and stakeholder surveys. All three
surveys consist of six to ten questions and are administered three times a
year. In fiscal year 2002, a total of $100,000 is available for these incentives.
The January 2001 surveys resulted in incentive payments totaling $2,704
out of a possible $3,004 paid to the RBHA, and $22,441 out of a possible
$29,726 paid to providers. Eleven providers earned incentives in that pe-riod.
The Department of Health Services suggested eliminating this pilot
program in September 2001 as part of its budget reduction proposal.
Finding II
21
OFFICE OF THE AUDITOR GENERAL
improved slightly over the first 5 years of the pilot program. Spe-cifically,
the percentage of providers responding “always” to
these questions increased from approximately 16 percent in 1997
to about 26.5 percent in January 2001.
Division does not survey other RBHAs’ providers—Instead of
surveying other RBHAs’ providers, the Division uses other
means for monitoring provider satisfaction. For example, in ad-dition
to the pilot program, the Division has a grievance mecha-nism
that allows dissatisfied providers to complain. In calendar
year 2000, providers filed 248 grievances, 246 of which were re-lated
to nonpayment. The Division also holds provider forums
and monthly meetings with providers. Results of the pilot pro-gram
and the number of grievances filed do not indicate wide-spread
dissatisfaction with RBHA services as rated by providers.
Provider satisfaction surveys could be expanded—The Division
may wish to proactively obtain feedback from providers regard-ing
quality of services provided by all five RBHAs. The Division
could administer the ten-question provider survey statewide to
measure RBHA services to providers. The Division should then
use the results of the survey to focus on RBHAs with low satis-faction
rates, because dissatisfaction could affect the quality of
behavioral health services clients receive. Further, because the
Division is dependent on RBHAs and providers to ensure there
is an adequate network in place to provide behavioral health
services to clients, the relationship between RBHAs and provid-ers
is important to the Division.
Division may wish to
survey providers of all
five RBHAs.
Finding II
22
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. The Division should continue its efforts to develop service-planning
guidelines for additional behavioral health diagno-ses.
2. The Division should consistently use its newly developed
uniform definitions for service availability performance
measures.
3. The Division should work to improve the response rate for
its consumer survey by considering alternative survey ad-ministration
methods, instead of relying on mail surveys.
4. The Division should consider expanding its survey of pro-viders
regarding their satisfaction with RBHA performance
to include all RBHAs.
OFFICE OF THE AUDITOR GENERAL
Appendix
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-i
Report name and description Frequency Preparer Recipient
Primary Source of
Requirememts
System-wide service appropriateness, delivery, and quality
reports. Enable recipients to monitor key aspects of service
delivery and system-wide operations.
1 Annual Report
Financial and programmatic report summarizing revenues
and expenditures, administrative costs, State Hospital
average daily census, accomplishments, and number of
people served by category.
Annually BHS Governor,
President of
Senate, and
Speaker of the
House of
Representatives
State Law
A.R.S §36-3405(A)(B)
2* Case File Review Report
RBHA staff review of Title XIX/XXI client files to determine
compliance with requirements for timeliness,
appropriateness, coordination of services, and inclusion of
client and family in service planning.
Annually RBHA BHS Federal Law
42 C.F.R. §434.53
3 Community Mental Health Services Performance Partnership
Block Grant Report Behavioral health system achievements,
problems with action plans, goals with measures, and
indicators.
Annually BHS Federal
SAMHSA
Grant
Performance Partnership
Block Grant
4 HB2003 Implementation Report
Progress report on mental health services funded by tobacco
litigation settlement monies.
Semi-
Annually
RBHA BHS State Law
Laws 2000,
Chapter 2, §1
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-ii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
5* Independent Quality Evaluation/Audit
Report from contracted specialist on services to clients.
Study based on provider case file review for particular
member group and can include interviews with key RBHA
staff.
Annually BHS AHCCCS Federal Law
45 C.F.R. §96-136
6 Medical Care Evaluation Study Results
Title XIX Level I inpatient and residential treatment centers’
report on results of their analysis of admissions, duration of
stay, and services. Includes recommendations for change, if
appropriate.
Annually Provider RBHA Federal Law
42 C.F.R. §456.141-145,
§456.241-245
7 Member Survey
Report on plan, implementation, and results of a client
satisfaction survey.
Biennially RBHA
BHS
BHS
AHCCCS
Federal Law
SSA §1932
8 Operational and Financial Review of the RBHAs
Includes financial reporting systems, and appropriateness of
service level determinations, congruence of services
authorized with level of care criteria and prior authorization
policy, appropriateness of case management services.
Annually RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §434.6, §434.50
9 Prevention Evaluation Report
Describes programs intended to prevent problems such as
substance abuse, domestic violence, school dropout, teen
pregnancy, and other problems. Includes program goals
and results.
Annually RBHA BHS Grant
Federal Substance Abuse
and Treatment (SAPT)
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-iii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
10 Quality Management/Utilization Management Plan (also called
Performance Improvement Plan)
Report on system to monitor RBHA compliance with
requirements in clinical care and administrative functions,
with progress on goals and objectives set in prior year’s
plan.
Annually BHS AHCCCS Federal Law
42 C.F.R. §456.6, §482.21,
§434.34, §456.100 et. seq.,
§456.200 et. seq.
11 Quality Management Report
Performance indicators and action plans for addressing
problems. Includes penetration rates, first service within 30
days of referral, symptomatic and health status outcomes,
inpatient days per thousand, average length of inpatient
stay, and trends in grievances.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §434.6, §434.34
12 Waiting Lists
Clients waiting for specified substance abuse services. Some
RBHAs also maintain for certain residential services.
Quarterly
or monthly
Provider
RBHA
RBHA
BHS
Grant
Federal SAPT
(Substance Abuse
Prevention and
Treatment)
13 Vocational Plan
Plan for increasing satisfactory employment of clients with
serious mental illness.
Annually RBHA BHS Contract
BHS/RBHA
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-iv
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
Program and project-specific reports. Enable stakeholders to
monitor specific programs and projects.
14 Annual Action Plan/Report
Plans and progress in meeting terms and conditions of the
J.K. Lawsuit Settlement Agreement.
Annually
(begins
11/01)
BHS and
AHCCCS
J.K. Lawsuit
defendants
Judicial
J.K. v. Eden settlement
agreement
15 Arizona Substance Abuse Treatment Needs Assessment
Substance use problems, treatment needs, and treatment
programs. BHS contracts with a variety of researchers,
including the University of Arizona Rural Health office, to
conduct the studies.
Annually BHS and
various
contracted
researchers
Federal
SAMSHA
Grant
Federal, State Substance
Abuse Needs Assessment
program
16 Arnold vs. Sarn Case File Reviews
Plans and progress in meeting terms and conditions of the
Arnold v. Sarn exit stipulation
Annually Value Op-tions/
BHS
Court
monitor
Judicial
Arnold v. Sarn exit
stipulation
17 Compulsive Gambling Treatment Program Report
Expenditures, services provided, and number of people
served through hotline and other services for compulsive
gamblers.
Quarterly BHS Lottery Contract:
Lottery/BHS
18 Correctional Officer/Offender Liaison Program Report
Substance abuse services for offenders released to
community supervision.
Quarterly RBHA BHS Contract
Department of
Corrections/BHS
19 Evaluation of Housing Approaches for the Seriously Mentally Ill
Evaluation of three approaches to housing people with a
serious mental illness: Supported housing, supportive
communities, and supervised apartments. BHS contracts
with three researchers, including Arizona State University,
to conduct the evaluations.
Once only,
at end of
project
(approx.
12/01)
BHS and
various
contracted
researchers
Federal
SAMHSA
Grant
Federal Supported
Housing Grant
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-v
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
20 Incentive Program Pilot
Survey results from clients, providers, and referring
agencies regarding RBHA performance. Used for
distributing incentive monies. Applies only to PGBHA.
Three times
per year
BHS Representative
Huppenthal
State Law
Laws 1994, Chapter 1, §24
21 Integrated Treatment Consensus Panel Evaluation
Evaluation of project to improve treatment of persons with
co-occurring mental health and substance abuse disorders.
Once only,
at end of
project
(1/31/02)
BHS and
University
of Arizona
Federal
SAMHSA
Grant
Federal Phase II
Community Action Grant
22 Inventory of Substance Abuse Prevention and Treatment
Programs
Program names/locations, funding, clients served
(number/demographics/problems), summary of services
provided, and evaluation of results achieved.
Annually Arizona
Drug &
Gang
Prevention
Resource
Center
(using
information
provided by
RBHAs)
Governor,
President of
the Senate,
Speaker of
the House
of
Representa-tives
State Law
A.R.S. §36-2023(c)
23 Mental Health Statistics Improvement Project (MHSIP) Report
Results of using common performance indicators with 15
other states in pilot project. Indicators incorporated into
BHS’ member survey.
Once only
at end of
project,
(7/1/02)
BHS Federal
Center for
Mental
Health
Services
(CMHS)
Grant
Federal MHSIP
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-vi
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
24 Project to Assist in Transition from Homelessness (PATH)
Report
Value Options, NARBHA, and CPSA only. Services and
clients served in program for homeless people with serious
mental illness; includes placements in housing.
Monthly
Annually
Provider
RBHA
BHS
RBHA
BHS
PATH
Grant
Federal PATH
25 Project MATCH (Multi-Agency Team for Children) Report
Accomplishments, services, and people served in a Pima
County program intended to provide an integrated system
of care for seriously emotionally disturbed children and
their families.
Quarterly BHS Federal
SAMHSA
Grant
Federal
SAMHSA
26 Status Report on the Terms and Conditions of the Exit Stipulation
For facilitating discussion in meetings with plaintiffs in
Arnold v. Sarn lawsuit. Includes update on strategic plans
for four areas, identified in a supplemental agreement to the
exit stipulation.
Three times
per year
BHS Court
monitor
and Arnold
v. Sarn
plaintiffs
Judicial
Arnold v. Sarn
Court monitor
27 Substance Abuse Prevention and Treatment (SAPT) Block Grant Report
Expenditures and services provided with the Block Grant
monies.
Annually BHS Federal
SAMHSA
Grant
Federal SAPT
Block Grant
Client protection reports. Enable report recipients to monitor
compliance with requirements related to client rights, safety, and
welfare.
28 Grievances and Appeals Report
Number and types of appeals and grievances filed by
members, providers, and RBHAs.
Quarterly Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §434.63
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-vii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
29 Incident and Accident Report
Summary of reported accidents, deaths, and incidents
including physical and sexual abuse.
Quarterly Provider RBHA Federal Law
42 C.F.R. §455.13
30 Incidents of Potential Fraud or Abuse
Observation and circumstances.
Upon
occurrence
RBHA
BHS
BHS
AHCCCS
State Law
A.R.S. §36-2918.01
31* Involuntary Commitment Report
Treatment plan and discharge summary for individuals
involuntarily committed to treatment by a Local Alcoholism
Reception Center (LARC) director’s petition.
Upon
occurrence
LARC BHS State Law
A.R.S. §36-2026.02(C)
32 Seriously Mentally Ill Client Mortality Report
Circumstances of death of client with serious mental illness.
Upon
occurrence
RBHA BHS State Regulation
Arizona Administrative
Code R9-21-409
33 Seriously Mentally Ill Client Seclusion and Restraints
Reports use of seclusion or restraints to manage client
behavior.
Monthly Provider RBHA State Regulation
Arizona Administrative
Code R9-21-204.(R)
34 Showing Report
Physician certifying need for Level I inpatient and
residential treatment center care.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §456.160
Provider network reports. Enable report recipients to monitor
service availability statewide.
35* Provider Affiliation Tape (also called Provider Network File)
Data for electronic matching of provider network
information between BHS and AHCCCS.
Monthly BHS AHCCCS Contract
AHCCCS/BHS
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-viii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
36 Provider Network Status Report (also called Provider Network
Evaluation and Sufficiency Report)
Narrative analysis of provider network sufficiency and list
of providers by geographic service area and type of service.
Annually RBHA
BHS
BHS
AHCCCS
Federal Law
SSA §1932
37 Provider Network Status Update/Report
Lists providers added and deleted, and changes in facilities’
licensure. Identifies material gaps in the provider network
and status of any corrective actions, including progress on
using technologies such as mapping software and
telemedicine.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
SSA §1932
38 Unexpected Changes That Could Impair the Provider Network
Provider termination, suspension, or failure to meet
licensing criteria.
Upon
occurrence
RBHA BHS Federal Law
SSA §1932
Service authorization and provision reports. Enable recipients
to monitor quantity and dollar value of services provided and
compliance with contractual stipulations defining who can
provide and receive services.
39 Encounter Reporting
Client services reported electronically from providers
through RBHAs and through BHS to AHCCCS. Encounter
data is used to set capitation rates and evaluate quality of
care.
Monthly Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-ix
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
Financial reports. Enable report recipients to monitor
contractor’s financial soundness and compliance with restrictions
on use of state and federal monies.
40 25th of the Month
Compares total expenditures for the month and year to date
as compared to prior years’ totals. Must also include
potential shortfalls in programs and potential federal and
other funds.
Monthly BHS Selected
legislators
and staff1
State Law
Laws 2001, Chapter 232,
§12
41 Budget
Budgeted schedule of revenues and expenses, required by
some RBHAs.
Annually Provider RBHA Contract
RBHA/Provider
42* Cost Allocation Plan
Defines direct and administrative costs and describes the
RBHA’s allocation methodology.
Annually RBHA BHS Federal Law
45 C.F.R. §95.501
Subpart E
43 Disclosure Statements
Ownership, related party transactions, creditors, board
members, key managers, and subcontractors.
Annually RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §455.100,
§1002.3,
§1124, §1128(a),
§1902(a)38
1 President of the Senate, Speaker of the House of Representatives, Chairmen of the Senate and House Appropriations Committees, and the Director of the Joint
Legislative Budget Committee.
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-x
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
44 Division Monthly Report
Shows Title XIX and non-Title XIX funding, administrative
and case management expenses, persons served, and units
of service by RBHA.
Monthly BHS Governor,
House
Speaker,
Senate
President
State Law
A.R.S.§36-3405(D)
45 Federal Financial Participation Reimbursement
Estimated cash requirements for outreach (ends 12/01)
Bi-weekly BHS AHCCCS Federal Law
Cash Management
Improvement Act
(CMIA) of 1990 (Public
Law 101-453) as
amended by CMIA of
1992 (Public Law 102-
589)
46 Financial Viability Ratios Statement
Ratios used for evaluating a RBHA’s financial condition.
Annually BHS AHCCCS Federal Law
42-C.F.R. §433.32, §434.50
47 Incurred But Not Reported Claims (also called Lag Report)
Costs associated with health care services incurred during a
financial reporting period but not reported to the prepaid
health care provider until after the reporting date.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32
48* Medications Report
Spending for psychotropic medications, and related client
and prescription counts.
Quarterly
Annually
RBHA BHS State Law
Laws 1998, Chapter 2, §8
and Laws 1999, Chapter
6, §5
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-xi
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
49* Non-Title XIX/XXI Children’s Behavioral Health Services
Summary (also called Grace Report)
Shows how money appropriated for children’s behavioral
health services is actually spent.
Monthly RBHA
BHS
BHS
Legislature
State Law
Laws 2001, Chapter 232,
§12
50 Notice of Real Property Transactions
Property purchase or sale notification.
Upon
Occurrence
RBHA BHS Contract
BHS/RBHA
51 Quarterly Expenditure Reports
Actual and projected administrative expenditures for
outreach activities (ends 12/31/01)
Quarterly BHS AHCCCS Federal Law
42 C.F.R. §433.32, §434.50
52 Schedule of Deferred Revenue
Revenues received but not yet earned, including the source
and use of the revenue.
Monthly RBHA BHS Contract
BHS/RBHA
53 Single Audit: Audited Financial Statements (draft and final)
Statement of financial position, statement of activities with
changes in net assets, statement of cash flows, functional
statement of expenses, and notes.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
54 Single Audit: OMB Circular A-133 Reports
Auditors’ reports on federal grant funding and compliance.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-xii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
55 Single Audit: Restated Fourth Quarter Statement of Activities
and Changes in Net Assets
Explains differences between year-end and audited
statement of activities based on auditor adjustments.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
56 Single Audit: Statement of Financial Position Reconciliation
Explains differences between year-end and audited financial
statements based on auditor adjustments.
Annually Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
Single Audit Act
Amendments of 1996 (all
organizations spending
$300,000 or more of
federal dollars)
57 Statement of Activities
Shows year-to-date revenue and expenses for Title XIX/XXI
and non-Title XIX/XXI. Quarterly report also includes
changes in net assets.
Quarterly;
monthly
from RBHA
Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Contract
AHCCCS/BHS
58 Statement of Cash Flows
Provides information about cash inflows and outflows
during the period.
Quarterly;
monthly
from RBHA
Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32, §434.50
59 Statement of Financial Position
Illustrates the financial position in balance sheet format.
Quarterly;
plus
monthly
from RBHA
Provider
RBHA
BHS
RBHA
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32, §434.50
60 Summaries of RBHA Financial Information
Summary reports; includes financial statements viability
ratio analysis, and analysis and review.
Quarterly RBHA
BHS
BHS
AHCCCS
Federal Law
42 C.F.R. §433.32, §434.50
Appendix
Behavioral Health System Reports
As of October 2, 2001
* Auditor General staff recommends streamlining, eliminating, or modifying the frequency of these reports (see Finding I, pages 5 through 12).
AHCCCS=Arizona Health Care Cost Containment System PGBHA=Pinal Gila Behavioral Health Authority
BHS=DHS Division of Behavioral Health Services RBHA=Regional Behavioral Health Authority
CFR=Code of Federal Regulations SAMHSA=Substance Abuse and Mental Health Services Administration
CPSA=Community Partnerships of Southern Arizona SSA=Social Security Act
NARBHA=Northern Arizona Regional Behavioral Health Authority Title XIX/Title XXI=Medicaid/KidsCare a-xiii
Report name and description Frequency Preparer Recipient
Primary Source of
Requirement
61* Tobacco Tax Cash Activity Statement
Cash flow of tobacco tax monies year-to-date. Includes
beginning cash balance, cash received, and cash disbursed.
Quarterly RBHA BHS Contract
BHS/RBHA
62 Tobacco Tax Evaluations Report
Use of monies allocated by A.R.S. §36-2921 for behavioral
health service program established in A.R.S. §36-3414.
Annually BHS JLBC State Law
A.R.S. §36-2907.071
63* Tobacco Tax Revenues and Expenditures Report
Revenues and expenditures of tobacco tax monies on an
accrual basis.
Quarterly RBHA BHS Contract
BHS/RBHA
1 In 2001, Senate Bill 1313 amended A.R.S. §36-2907.07, changing reporting requirements for tobacco tax evaluations beginning on July 1, 2002. The Auditor
General is to evaluate and report on tobacco tax programs administered by the Department of Health Services, with the first report due on November 15,
2004.
OFFICE OF THE AUDITOR GENERAL
Agency Response
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
Debra K. Davenport
Auditor General
2910 N. 44th Street
Phoenix, Arizona 85008
Dear Ms. Davenport:
Thank you for an opportunity to respond to your office's review of the behavioral health
system's reporting requirements.
We agree with the report and plan to implement all of its recommendations. We
commend the audit team for developing a thorough understanding of our reporting
requirements, our performance measurement system, and our quality improvement
efforts.
Once again, thank you for your professionalism and your fair and thorough evaluation.
Sincerely,
Catherine R. Eden
Director
Other Performance Audit Reports Issued Within
the Last 12 Months
01-10
Future Performance Audit Reports
Arizona State Lottery Commission
Arizona Health Care Cost Containment System
01-1 Department of Economic Security—
Child Support Enforcement
01-2 Department of Economic Security—
Healthy Families Program
01-3 Arizona Department of Public
Safety—Drug Abuse Resistance
Education (D.A.R.E.) Program
01-4 Arizona Department of
Corrections—Human Resources
Management
01-5 Arizona Department of Public
Safety—Telecommunications
Bureau
01-6 Board of Osteopathic Examiners in
Medicine and Surgery
01-7 Arizona Department
of Corrections—Support Services
01-8 Arizona Game and Fish Commission
and Department—Wildlife
Management Program
01-9 Arizona Game and Fish
Commission—Heritage Fund
01-10 Department of Public Safety—
Licensing Bureau
01-11 Arizona Commission on the Arts
01-12 Board of Chiropractic Examiners
01-13 Arizona Department of
Corrections—Private Prisons
01-14 Arizona Automobile Theft
Authority
01-15 Department of Real Estate
01-16 Department of Veterans’ Services
Arizona State Veteran Home,
Veterans’ Conservatorship/
Guardianship Program, and
Veterans’ Services Program
01-17 Arizona Board of Dispensing
Opticians
01-18 Arizona Department of Correct-ions—
Administrative Services
and Information Technology
01-19 Arizona Department of Education—
Early Childhood Block Grant
01-20 Department of Public Safety—
Highway Patrol
01-21 Board of Nursing
01-22 Department of Public Safety—
Criminal Investigations Division
01-23 Department of Building and
Fire Safety
01-24 Arizona Veterans’ Service
Advisory Commission
01-25 Department of Corrections—
Arizona Correctional Industries
01-26 Department of Corrections—
Sunset Factors
01-27 Board of Regents
01-28 Department of Public Safety—
Criminal Information Services
Bureau, Access Integrity Unit, and
Fingerprint Identification Bureau
01-29 Department of Public Safety—
Sunset Factors
01-30 Family Builders Program
01-31 Perinatal Substance Abuse
Pilot Program
01-32 Homeless Youth Intervention
Program